Nurse’s note: Client body position slumped forward in chair, with head on bedside table, and no eye contact.

Client slow to verbally respond to Questions.

Vital signs noted, no change in condition at this time.

Denies any pain or discomfort at this time.

Requesting to speak to a chaplain at this time.

Which are included in the 5 stages of grief? (Select all that apply)

Choice A rationale
The first physiological response that occurs during the General Adaptation Syndrome (GAS) is
the alarm reaction stage. This stage is the body’s initial response to stress, where the sympathetic nervous system is activated by the sudden release of hormones.
Choice B rationale
The body remaining alert while blood pressure and heart rate return to pre-stress levels is part of the resistance stage of GAS, not the first physiological response.
Choice C rationale
Prolonged exposure to stress resulting in illness is associated with the exhaustion stage of GAS, which is the final stage, not the first physiological response.
Choice D rationale
An increase in hormones causing an increase in blood pressure and heart rate is part of the alarm reaction stage, but it is not the first physiological response. The first response is the perception of a stressor that stimulates the central nervous system.

Choice A rationale
Holding the pain medication until the patient wakes up is not the best choice. Pain can disrupt sleep, and it’s important to keep the patient as comfortable as possible. If the patient is sleeping, it may be because the pain is well-controlled, and delaying the medication could lead to a return of pain.
Choice B rationale
The patient should be given the scheduled pain medication. This is the best choice because it ensures that the patient’s pain is managed effectively. Even if the patient is sleeping, the medication should be given to prevent the pain from returning.
Choice C rationale
Calling the family and asking if the patient would like to be woken up to have their pain medication is not the best choice. The nurse should make this decision based on the patient’s pain level and the medication schedule, not on the family’s preferences.
Choice D rationale
The statement that the patient has become addicted to the medication and is sleeping the last dose off is not accurate. Addiction is a complex condition characterized by compulsive drug use despite harmful consequences. In this case, the patient is receiving the medication for a legitimate medical reason, and there is no indication of addiction.