The nurse is caring for 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?

Offer a referral to pastoral counseling.

Suggest the need for a psychiatric consultation.

Explore changes in life that have occurred after the loss.

Encourage attending a local support group.

Answer and Explanation

The Correct Answer is C

A) Offering a referral to pastoral counseling can be helpful, but it may not address the immediate emotional needs of the client who is experiencing extreme sadness and difficulty controlling emotions. This option can be considered later in the therapeutic process.

B) Suggesting the need for a psychiatric consultation might be appropriate, but it could be premature at this point. The focus should first be on understanding the client’s current emotional state and helping them process their grief.

C) Exploring changes in life that have occurred after the loss is the first and most important action. This approach allows the nurse to facilitate the client’s expression of feelings, which is crucial in the grieving process. By discussing the impact of the loss, the nurse can provide emotional support and help the client begin to process their grief.

D) Encouraging attendance at a local support group can be beneficial, but it may not be the most immediate action. The client needs to be heard and understood in their current emotional state before considering additional resources or support systems.

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Correct Answer is C

Explanation

A) Listening to what the client is saying can be important for understanding their perspective, but in this situation, the client's loud and wild behavior may be disruptive or alarming to others. Prioritizing safety is crucial.

B) Sitting in the chair next to the client could help establish rapport, but it does not address the immediate need to manage the disruptive behavior. The nurse must first ensure a safe environment for all clients.

C) Escorting the client to his room is the best initial action. This intervention helps to remove the client from the potentially stimulating environment of the day room, reducing the likelihood of escalation and providing a quieter space where the client can feel more secure and calm. It also minimizes disruption to other clients.

D) Administering a PRN sedative may be necessary if the behavior continues to escalate, but it should not be the first action taken. Non-pharmacological interventions, such as providing a safe space, should be prioritized before considering medication.

A. Provide education on methods to enhance sleep. B. Encourage the client to exercise. C. Teach the client to develop a plan for daily structured activities. D. Suggest that the client develop a list of pleasurable activities.

Correct Answer is C

Explanation

A) Providing education on methods to enhance sleep may be helpful, especially since hypersomnia is a symptom. However, simply focusing on sleep does not address the broader functional impairments that the client is experiencing. While improving sleep hygiene can contribute to overall well-being, it is not the most comprehensive approach for facilitating a return to normal functioning.

B) Encouraging the client to exercise can be beneficial, as physical activity is known to have positive effects on mood and energy levels. However, for someone experiencing significant psychomotor retardation and amotivation, initiating an exercise routine can be daunting and may not be the most immediate or effective intervention. A structured approach is often more helpful in these cases.

C) Teaching the client to develop a plan for daily structured activities is likely to be the most effective intervention. Structured activities provide a framework that can help combat psychomotor retardation and amotivation by breaking down tasks into manageable parts. This approach encourages the client to engage in routine, which can gradually enhance motivation and overall functioning, helping them feel a sense of accomplishment and purpose.

D) Suggesting that the client develop a list of pleasurable activities could provide some motivation, but it may not be sufficient on its own, especially given the client's current level of amotivation. While identifying pleasurable activities is valuable, it is essential to pair this with a structured plan that encourages active participation and accountability, making the structured activities approach more effective in this context.

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The nurse is caring for 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit's day room. Which action should the nurse implement first?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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