A nurse is planning to use the nursing process to care for a client who is experiencing grief.
Which of the following actions should the nurse take first?
Establish whether the client's grieving is healthy or complicated.
Develop client-specific goals and outcomes.
Incorporate the treatment into the client's care.
Determine whether coping strategies were successful.
The Correct Answer is A
Choice A rationale:
Establishing whether the client's grieving is healthy or complicated is the first step in the nursing process when caring for a client experiencing grief. This step falls under the assessment phase of the nursing process and is essential for understanding the client's needs and planning appropriate care.
Choice B rationale:
Developing client-specific goals and outcomes comes after the assessment phase in the planning stage of the nursing process. While important, it is not the first action the nurse should take in this situation.
Choice C rationale:
Incorporating the treatment into the client's care occurs during the implementation phase of the nursing process and follows assessment and planning. This is not the first action.
Choice D rationale:
Determining whether coping strategies were successful is part of the evaluation phase of the nursing process, which occurs after the implementation of care. It is not the first step in this situation. Now, let's proceed to the final question.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Keeping the feet together when lifting an object is not a proper body mechanics technique. It can lead to instability and an increased risk of injury because the base of support is not wide enough. Therefore, this choice does not indicate an understanding of body mechanics.
Choice B rationale:
Bending at the hip when lifting is also an incorrect body mechanics technique. Proper body mechanics involve bending at the knees and keeping the back straight to reduce the risk of back injuries. Bending at the hips can strain the lower back, making it an incorrect choice.
Choice C rationale:
Twisting the spine when lifting is a harmful practice in body mechanics. Twisting the spine can lead to spinal injuries, especially when lifting heavy objects. Proper body mechanics emphasize keeping the spine aligned and not twisting during lifting. Therefore, this choice does not indicate an understanding of body mechanics.
Choice D rationale:
Standing close to the object being moved is the correct body mechanics technique. This choice demonstrates an understanding of proper body mechanics because it reduces the strain on the back and minimizes the effort required to lift a heavy object. Keeping a wide base of support and using the leg muscles rather than the back muscles are essential principles of proper body mechanics. This is the correct choice. .
Correct Answer is D
Explanation
Choice A rationale:
Decreased thickness of tympanic membranes is not a typical physiological change in older adults. Tympanic membranes tend to become thinner and less flexible with age, leading to increased susceptibility to damage, not decreased thickness.
Choice B rationale:
Decreased tinnitus is not a physiological change related to aging. Tinnitus can occur in individuals of all ages and is often associated with various factors such as exposure to loud noises, ear infections, or underlying medical conditions.
Choice C rationale:
Decreased ear wax is not a typical physiological change in older adults. In fact, older adults may experience increased production of earwax, which can lead to hearing problems if not managed appropriately.
Choice D rationale:
Decreased ability to hear high-frequency sounds is a common physiological change in older adult clients. This change, known as presbycusis, is characterized by a reduced ability to hear high-pitched sounds due to changes in the inner ear, including damage to hair cells and changes in the auditory nerves. Presbycusis is a well-documented and expected age-related change in hearing.
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