The nurse is caring for a client who is experiencing extreme sadness after the passing of a companion of 30 years. The client describes not being able to think of other things and finds it difficult to control emotions. Which action should the nurse take first?
Explore changes in life that have occurred after the loss.
Suggest the need for a psychiatric consultation.
Offer a referral to pastoral counseling.
Encourage attending a local support group.
The Correct Answer is A
Choice A rationale:
Exploring changes in life that have occurred after the loss is the first action the nurse should take. This allows the nurse to assess the client's grief, identify specific stressors, and understand how the loss is impacting the client's daily life and emotional well-being. It provides valuable information for tailoring further interventions and support.
Choice B rationale:
Suggesting the need for a psychiatric consultation may be premature as the nurse should first assess the client's grief and coping mechanisms. Referral for psychiatric consultation should be considered if the client's emotional distress is severe, persistent, or significantly impacting their functioning.
Choice C rationale:
Offering a referral to pastoral counseling may be appropriate for some clients, but it should not be the first action. The nurse should assess the client's needs and preferences before making such a referral.
Choice D rationale:
Encouraging attendance at a local support group can be beneficial, but it should not be the initial step. The nurse should first assess the client's current emotional state and needs to determine the most appropriate interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Sweet potatoes are not typically high in oxalates and are generally considered safe to consume in moderation for individuals with calcium oxalate renal stones.
Choice B rationale:
Spinach is high in oxalates, which can contribute to the formation of calcium oxalate renal stones. Therefore, the client should be instructed to avoid spinach and foods high in oxalates.
Choice C rationale:
Bananas are generally low in oxalates and are not likely to be a significant contributor to the formation of calcium oxalate renal stones. They are safe for most individuals to consume.
Choice D rationale:
Fish is generally not high in oxalates and is not a major concern for individuals with calcium oxalate renal stones. However, it's essential to maintain an overall balanced diet and stay hydrated to prevent stone formation.
Correct Answer is ["B","C","D","E","F"]
Explanation
Choice A rationale:
This finding suggests that the client may not be fully disclosing her symptoms or may not be aware of their significance. It should be investigated further.
Choice B rationale:
The blood pressure and heart rate are within an acceptable range, indicating that the client's blood pressure is relatively stable.
Choice C rationale:
A potassium level of 3.6 mEq/L falls within the reference range, indicating that the client's potassium level is within normal limits.
Choice D rationale:
The client's commitment to attending dialysis appointments is a positive sign, as regular dialysis is crucial for managing end-stage renal disease.
Choice E rationale:
If the client recognizes the need to resume her Lisinopril for blood pressure control, it indicates her understanding of the medication's importance in managing her hypertension.
Choice F rationale:
The client's willingness to incorporate nutrient-rich foods like dark green vegetables and potatoes into her diet is a positive sign for improving her nutritional status, which can be beneficial for her overall health. However, dietary changes should be discussed with her healthcare provider to ensure they are appropriate for her condition.
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