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 A
Explanation
Choice A rationale:
"Keep your back straight.”. Maintaining correct posture when transferring clients is essential to prevent injuries to both the nurse and the patient. The correct answer, "Keep your back straight," is crucial in ensuring that the nurse avoids straining their back muscles. When transferring patients, it's essential to use proper body mechanics and keep the spine in a neutral position. This minimizes the risk of back injuries and promotes safe patient handling. Bending or twisting the back can lead to musculoskeletal problems, such as back pain or herniated discs.
Choice B rationale:
"Keep your knees straight.”. Keeping your knees straight is not the correct choice for maintaining correct posture when transferring clients. In fact, it's essential to keep your knees slightly bent when lifting or transferring a patient. This position helps to maintain stability and distribute the weight evenly, reducing the risk of injury.
Choice C rationale:
"Tilt your head toward your chest.”. Tilting the head toward the chest is unrelated to maintaining proper posture during patient transfers. It is important to keep the head in a neutral position while transferring patients, focusing on the back and leg positioning.
Choice D rationale:
"Loosen your abdominal muscles.”. Loosening abdominal muscles is not a recommended practice during patient transfers. Maintaining core strength and stability is essential for proper body mechanics. Relaxing the abdominal muscles can lead to poor posture and decreased stability, increasing the risk of injury.
Correct Answer is B
Explanation
Choice A rationale:
Increased sensitivity to touch is not typically an age-related change in older adults. In fact, older adults often experience a decrease in sensitivity due to factors like reduced skin elasticity and changes in nerve function.
Choice C rationale:
Increased peripheral vision is not a common age-related change. Visual changes in older adults usually involve decreased visual acuity, difficulties with night vision, and increased sensitivity to glare.
Choice D rationale:
An increase in the size of pupils is not an expected age-related change. Pupils may become smaller and react more sluggishly to changes in light in older adults, but a consistent increase in pupil size is not a common finding.
Choice B rationale:
An increase in cerumen in the ear canal is a common age-related change. Cerumen, or earwax, can accumulate more in older adults due to changes in the composition of earwax and slower migration of earwax out of the ear canal. It can lead to hearing difficulties and may need management. Moving on to the last question.
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