A nurse is planning care for a client who has complicated grieving following the death of their child. Which of the following interventions should the nurse identify as the priority?

Identify the client's current stage of grief.

Encourage the client to participate in physical activities.

Discuss the use of a spiritual grief counselor with the client.

Inform the client that feelings of anger are expected.

Answer and Explanation

The Correct Answer is A

Choice A reason: Identifying the client's current stage of grief is crucial as it helps tailor the intervention to the client's specific needs. Understanding where the client is in the grieving process allows the nurse to provide appropriate emotional support and resources. It's the foundational step in managing complicated grief, as interventions may vary greatly depending on whether the client is in denial, anger, bargaining, depression, or acceptance.

Choice B reason: While physical activity can be beneficial for overall health and may help in managing symptoms of depression associated with grief, it is not the immediate priority. The nurse must first understand the client's emotional state before suggesting specific activities.

Choice C reason: Discussing the use of a spiritual grief counselor can be a valuable part of the healing process for some clients. However, this should come after assessing the client's beliefs and willingness to engage in spiritual counseling. It is not the first step in the care plan.

Choice D reason: Informing the client that feelings of anger are expected is part of educating the client about the grieving process. While it's important to normalize the range of emotions experienced during grief, it is more of a supportive intervention rather than a priority action.

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Correct Answer is B

Explanation

Choice A reason: Telling the client that the symptoms will improve over time without further assessment could be misleading. These symptoms could indicate lithium toxicity, which requires immediate medical attention.

Choice B reason: Lethargy, muscle weakness, and blurred vision can be signs of lithium toxicity. The nurse should recommend blood tests to check lithium levels and kidney function to rule out toxicity.

Choice C reason: Decreasing sodium intake is not recommended without a healthcare provider's advice, as sodium levels can affect lithium levels in the body. Sudden changes in sodium intake should be avoided unless directed by a healthcare provider.

Choice D reason: Continuing the medication as prescribed without addressing the symptoms could be dangerous. The symptoms reported by the client need to be evaluated to ensure they are not due to lithium toxicity.

A. Suppression B. Sublimation C. Projection D. Rationalization

Correct Answer is D

Explanation

Choice A reason: Suppression is a conscious decision to delay paying attention to an emotion or need in order to cope with the present reality. It's unlikely that the client is consciously choosing to ignore the cause of their blackouts.

Choice B reason: Sublimation is a way of dealing with unacceptable impulses by unconsciously substituting acceptable forms of expression. This defense mechanism doesn't typically apply to explaining symptoms like blackouts.

Choice C reason: Projection involves attributing one's own unacceptable thoughts or feelings to another person. Since the client is providing an explanation for their own symptoms, rather than attributing them to someone else, projection is not the defense mechanism at play here.

Choice D reason: Rationalization involves justifying behaviors or feelings with logical reasons, even if they are not appropriate. The client's attribution of blackouts to low blood sugar, despite a diagnosis that suggests a psychological cause, is a form of rationalization.

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A nurse is planning care for a client who has complicated grieving following the death of their child. Which of the following interventions should the nurse identify as the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is taking lithium and reports experiencing lethargy, muscle weakness, and blurred vision. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is assessing a client who has a recent diagnosis of dissociative identity disorder. The client tells the nurse, "I think my blackouts are actually caused by low blood sugar." The nurse should recognize the client is using which of the following defense mechanisms?

Correct Answer is D

Explanation

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