The nurse is speaking with the spouse of a client who has passed away unexpectedly. The spouse is very calm and says, "No, there must be a mistake." Which action should the nurse take?

Request a spiritual advisor's consult.

Encourage viewing of the body to accept the death.

Provide support of the spouse's feelings.

Ask the relatives about how the spouse is coping.

Answer and Explanation

The Correct Answer is C

A. Request a spiritual advisor's consult: This may be helpful later but is not the nurse’s first responsibility. The immediate need is to support the spouse emotionally through the initial shock.

B. Encourage viewing of the body to accept the death: While this may eventually assist with acceptance, it can feel rushed or harsh if suggested before acknowledging the spouse’s current emotional state.

C. Provide support of the spouse's feelings: Denial is a normal initial reaction to grief. Supporting the spouse’s emotional response is the most appropriate and immediate nursing action.

D. Ask the relatives about how the spouse is coping: This shifts focus away from the grieving spouse, who is the primary concern at this moment and requires direct support.

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Correct Answer is C

Explanation

A. Provide handouts written at a 12th grade reading level: Educational materials should be written at an appropriate reading level for the client, typically 6th to 8th grade for older adults, to promote understanding. Handouts at a 12th-grade level might be too complex.

B. Use background music to promote relaxation: While this could potentially help reduce anxiety for some people, it may also be distracting for others during important health teaching. The priority is clear and focused communication.

C. Turn on overhead lights while giving instructions: Proper lighting is essential, especially for older adults who may have visual impairments. Bright, direct lighting can help ensure the client clearly sees instructional materials and feels more comfortable during teaching.

D. Stand behind the client to avoid intimidation: Standing behind the client can be intimidating and might make the interaction feel less personal. It's important to engage the client in a way that encourages open communication, typically by sitting or standing at eye level.

A. Determine how long the client has been lying prone. B. Measure the client's vital signs. C. Inspect the dressing on the stump. D. Assist the client in turning to a position of comfort.

Correct Answer is A

Explanation

A. Determine how long the client has been lying prone: Prone positioning is used post-amputation to prevent hip flexion contractures. However, prolonged periods in this position can cause discomfort or complications. Knowing the duration helps evaluate if it’s appropriate to reposition or maintain it for therapeutic reasons.

B. Measure the client's vital signs: Vital signs are important in the postoperative period, but this task can be completed after addressing the client’s immediate request and assessing the potential impact of their current positioning on healing and comfort.

C. Inspect the dressing on the stump: Inspecting the stump is crucial for monitoring for infection or bleeding. However, unless there is a concern based on symptoms or reports from the client, it should follow assessment of position and comfort needs.

D. Assist the client in turning to a position of comfort: Turning the client without assessing how long they have been prone could interfere with therapeutic positioning aimed at preventing complications like hip contractures, especially in early postoperative care.

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The nurse is speaking with the spouse of a client who has passed away unexpectedly. The spouse is very calm and says, "No, there must be a mistake." Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Correct Answer is A

Explanation

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