A nurse is reinforcing teaching with the family of a client who is terminally ill about the grief process. Which of the following information should the nurse include in the teaching?

The grieving process should be complete within 1 year.

Anticipatory grieving prolongs the grief process.

Anger toward the health care staff is expected.

The stages of grief occur in sequential order.

Answer and Explanation

The Correct Answer is C

A. The grieving process should be complete within 1 year.: This is incorrect. Grief is a highly individual process and does not follow a strict timeline. It can last longer than one year for some individuals, depending on the relationship and circumstances.

B. Anticipatory grieving prolongs the grief process.: This is incorrect. Anticipatory grief, the grief experienced before the loss occurs, does not necessarily prolong the grieving process. In fact, it may help some individuals cope better after the loss because they have already begun to process their emotions.

C. Anger toward the health care staff is expected.: This is correct. It is normal for family members to experience anger during the grieving process, and sometimes they may direct it toward the healthcare staff, especially if they feel that the care is inadequate or if they are overwhelmed by emotions.

D. The stages of grief occur in sequential order.: This is incorrect. While Elisabeth Kübler-Ross identified five stages of grief (denial, anger, bargaining, depression, and acceptance., they do not necessarily occur in a linear or sequential order. Individuals may experience them in different ways and revisit stages at different times.

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Correct Answer is A

Explanation

A. Client-stated, "I lost my balance and fell when I got out of bed to go to the bathroom." This is the correct choice. The nurse should document the client's own account of the event in the medical record. It is important to accurately record the client's statement, as documentation should reflect the facts and avoid interpretation or assumptions.

B. "An incident report has been completed and sent to risk management." This statement should not be included in the client's medical record. Incident reports are separate from clinical documentation and are not part of the patient's permanent medical record.

C. "The client fell because the assistive personnel did not place nonskid slippers on the client." This statement makes an assumption about the cause of the fall and includes blame, which is inappropriate for medical documentation. Documentation should focus on objective observations and the client's statement, not assigning fault.

D. "The client does not appear to have any injuries resulting from the fall." While the nurse may assess the client for injuries, this statement should not be included unless it is confirmed and part of a thorough, objective assessment. It’s important to document specific findings (e.g., "No visible injuries noted").

A. "Self-administer oxygen through your nasal cannula at 6 milliliters per minute during meals." B. "Drink at least 240 milliliters of water during each meal." C. "Perform pulmonary hygiene 1 hour before meals." D. "Lie down for 30 minutes after eating."

Correct Answer is C

Explanation

A. "Self-administer oxygen through your nasal cannula at 6 milliliters per minute during meals." is incorrect. Oxygen should not typically be increased during meals unless specifically prescribed by the provider. If the client has difficulty eating due to breathlessness, a more individualized plan is needed.

B. "Drink at least 240 milliliters of water during each meal." is incorrect. Clients with COPD may have difficulty breathing when consuming large amounts of fluids during meals. Overhydration could also worsen fluid retention in some cases. The amount of fluid should be tailored to the client’s needs and prescribed by the healthcare provider.

C. "Perform pulmonary hygiene 1 hour before meals." is correct. Pulmonary hygiene (such as postural drainage, coughing techniques, and deep breathing exercises) should be performed before meals to clear the airways and improve the ability to breathe while eating, preventing aspiration and difficulty breathing.

D. "Lie down for 30 minutes after eating." is incorrect. Lying down after eating can increase the risk of aspiration, especially in clients with COPD who may already have a compromised respiratory system. The client should be advised to remain upright after meals to prevent reflux and aspiration.

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A nurse is reinforcing teaching with the family of a client who is terminally ill about the grief process. Which of the following information should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation?

Correct Answer is A

Explanation

A nurse is reinforcing discharge teaching with a client who has COPD and reports problems with maintaining adequate nutrition. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

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