The nurse is caring for a child who has a diagnosis of metastatic brain cancer. The father states "I can't believe this is happening to us, I feel numb." Which of the following nursing interventions by the nurse is the first priority?
Instruct the family about anticipatory grieving
Explore effective ways of family coping
Encourage the family’s expression of their feelings
Discuss the disease and its manifestations with family members
The Correct Answer is C
A. Instruct the family about anticipatory grieving: While anticipatory grieving is important, it is better addressed after the family has had time to express initial feelings.
B. Explore effective ways of family coping: This is important but should come after encouraging the family to process their immediate feelings.
C. Encourage the family’s expression of their feelings. The first priority is to allow the family to express their emotions and begin the grieving process. Encouraging emotional expression helps the family cope with the overwhelming news and facilitates their emotional support needs.
D. Discuss the disease and its manifestations with family members: While understanding the disease is essential, focusing on the family's emotional response is more critical at this initial stage of shock and grief.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Determine the location of the pain. The nurse should first assess the client's pain, including its location, intensity, quality, and factors that alleviate or exacerbate it. This assessment is critical to determining the most appropriate intervention and evaluating the effectiveness of the treatment.
B. Reposition the client: Repositioning is a valid nursing intervention for managing pain caused by discomfort or poor positioning. However, it should not be the first action, as the nurse must first assess the pain to determine if repositioning alone is sufficient or if medication is necessary.
C. Review the effects of the pain medication: While reviewing the effects of the prescribed medication is important to ensure its appropriateness and safety, this step is part of preparation for medication administration. It is not the first action; assessment of the client's pain takes priority.
D. Administer the medication: Administering pain medication without assessing the client's pain is not appropriate. Pain management should be individualized, and assessment ensures that the prescribed medication is suitable for the client's current pain and condition.
Correct Answer is B
Explanation
A. Encourage visitors throughout the day: Increased visitor interactions may worsen sensory overload by adding more stimuli.
B. Provide the client with earplugs. Earplugs help reduce environmental noise and sensory input, addressing the client's sensory overload and promoting rest and comfort.
C. Spread client care activities throughout the shift: Consolidating care activities, rather than spreading them out, minimizes interruptions and helps reduce sensory input.
D. Keep the door to the client's room open: Keeping the door open can increase noise and stimuli, exacerbating sensory overload.
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