A nurse is reviewing the medical history of a client who is scheduled for surgery.
Which of the following findings places the client at risk for an incisional hematoma?

Choice A rationale:

"Depends on their friends for emotional support.”. While it's common for adolescents to rely on their friends for emotional support, this behavior is not necessarily indicative of a problem. Depending on friends for emotional support can be a healthy part of adolescent development, and it does not specifically relate to the loss of a parent.

Choice B rationale:

"Clings to their caregiver.”. The correct answer, "Clings to their caregiver," is a common response to the loss of a parent in adolescence. When adolescents experience the death of a parent, they often feel a strong need for emotional support and security. They may cling to their remaining caregiver, seeking comfort and reassurance during this challenging time.

Choice C rationale:

"Exhibits toileting problems.”. Exhibiting toileting problems can be a potential response to stress and emotional distress, but it is not the most expected or specific finding when a parent has recently died. This behavior may be more common in younger children who are still developing their coping mechanisms.

Choice D rationale:

"Reports tightness in their chest.”. While emotional distress can manifest physically, such as chest tightness, it is not the most characteristic finding when a parent has recently died. Clinging to a caregiver and seeking emotional support are more typical responses in adolescents.

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.