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:
Increasing the heat in the client's room is not the appropriate action for managing dyspnea. Dyspnea, or difficulty breathing, is not typically related to room temperature. Other interventions should be prioritized.
Choice B rationale:
Performing nasotracheal suctioning for the client is not the initial action to address dyspnea at the end of life. Suctioning is indicated when there is excessive secretions or airway obstruction but should not be the first intervention for dyspnea.
Choice C rationale:
Placing the head of the client's bed flat is not the best action for a client experiencing dyspnea. Elevating the head of the bed (Fowler's position) is the recommended position to improve lung expansion and reduce dyspnea in clients with breathing difficulties.
Choice D rationale:
Administering an opioid narcotic to the client is the most appropriate action for managing dyspnea at the end of life. Opioid medications, such as morphine, are often used to relieve severe dyspnea in hospice and palliative care settings. These medications can help relax the client and reduce the sensation of breathlessness. .
Correct Answer is D
Explanation
Choice A rationale:
Tightening abdominal muscles is not the first action the nurse should take when repositioning a client. Repositioning a client requires proper body mechanics and coordination. Tightening abdominal muscles may not be as effective or safe as other actions in ensuring the client's safety during repositioning.
Choice B rationale:
Raising the height of the client's bed is not the first action the nurse should take when repositioning a client. Adjusting the bed height is a secondary consideration and can be done after ensuring proper body mechanics and patient safety during the repositioning process.
Choice C rationale:
Pivoting the feet in the direction of the move is a crucial step when repositioning a client. This action allows the nurse to maintain balance and control during the transfer. It also reduces the risk of injury to the nurse and the client. However, it is not the first action to be taken.
Choice D rationale:
Placing the feet in line with the shoulders is the first action the nurse should take when repositioning a client. This wide base of support provides stability and balance. It allows the nurse to maintain control during the repositioning process, reducing the risk of injury to both the nurse and the client. After achieving this stable stance, pivoting the feet in the direction of the move is the next step to facilitate the repositioning.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.