When the parents of a 6-year-old boy with a brain tumor are told that his condition is terminal, the mother shouts at the father, "This is your fault! It never would have happened if we had sought treatment sooner!" Which intervention is best for the nurse to implement?

Refer the parents to the chaplain to provide grief counseling.

Tell the parents that blaming each other will not change the situation

Assure the parents that a terminal diagnosis is inevitable.

Explain to the parents that anger is a common response to grief.

Answer and Explanation

The Correct Answer is D

The correct answer is choice d. Explain to the parents that anger is a common response to grief.

Choice A rationale:

Referring the parents to the chaplain for grief counseling can be beneficial, but it may not address the immediate emotional outburst and the need for understanding their feelings.

Choice B rationale:

Telling the parents that blaming each other will not change the situation might be true, but it can come across as dismissive and may not provide the emotional support they need at that moment.

Choice C rationale:

Assuring the parents that a terminal diagnosis is inevitable does not address their current emotional state and may seem insensitive to their grief and anger.

Choice D rationale:

Explaining to the parents that anger is a common response to grief helps them understand their emotions and provides immediate emotional support, making it the best intervention in this situation.

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Correct Answer is B

Explanation

In this situation, the client has a fingerstick glucose level of 35 mg/dL (1.94 mmol/L) and is alert but diaphoretic. The charge nurse should take the following action:

Give the client a glass of orange juice.

A glucose level of 35 mg/dL (1.94 mmol/L) is considered significantly low (hypoglycemia), and the client's symptoms of diaphoresis indicate that the low glucose level is likely causing the symptoms. Providing the client with a glass of orange juice or another source of fast-acting carbohydrate is appropriate to quickly raise the blood sugar level and alleviate the symptoms of hypoglycemia.

Collecting a blood sample for hemoglobin A1c (HbA1c) is not necessary in this acute situation. HbA1c reflects the average blood glucose level over the past 2-3 months and is used to assess long-term glycemic control in clients with diabetes. It does not provide immediate information or guide immediate interventions for acute hypoglycemia.

Notifying the healthcare provider is not the first action to take in this situation. The client's low glucose level can be promptly addressed by administering a source of fast-acting carbohydrate, such as orange juice. If the client's symptoms persist or worsen despite appropriate intervention, or if there are other concerning factors, then notifying the healthcare provider would be appropriate.

Assessing the client for polyuria (excessive urination) and polyphagia (excessive hunger) is important in the overall management of diabetes, but it is not the immediate action to take in this acute situation of hypoglycemia. The priority at this time is to address the low blood sugar level and relieve the client's symptoms.

A. Provide a printed health care assessment form. B. Defer the health history until the client is less anxious. C. Ask the family member to answer the questions. D. Assess the surroundings for noise and distractions.

Correct Answer is D

Explanation

The ability to effectively communicate and provide accurate information can be impacted by external factors such as noise, distractions, or an unfamiliar environment. By assessing the surroundings, the nurse can identify and address any potential barriers to communication.

Once the nurse has addressed any environmental factors that may be hindering communication, they can proceed with other strategies to facilitate the health history assessment. This may include providing a printed healthcare assessment form to assist the client in organizing their thoughts or deferring the assessment until the client is less anxious.

Asking the family member to answer the questions should be considered if the client is unable to provide accurate information or is cognitively impaired. However, it is important to first address any environmental factors and attempt to engage the client directly in the assessment process.

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When the parents of a 6-year-old boy with a brain tumor are told that his condition is terminal, the mother shouts at the father, "This is your fault! It never would have happened if we had sought treatment sooner!" Which intervention is best for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) reports that a client who has a fingerstick glucose of 35 mg/dL (1.94 mmol/L) is alert and diaphoretic. Which action should the charge nurse take? Reference Ranges Glucose [Reference Range: 0 to 50 years: 74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

Correct Answer is B

Explanation

An older client comes to the clinic with a family member. When the nurse attempts to take the client's health history, the client does not respond to questions in a clear manner. Which action should the nurse implement first?

Correct Answer is D

Explanation

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