Nokea
A client diagnosed with a severe ulcer of the right foot is told that a right leg amputation may be necessary. Which signs or client behaviors indicative of anticipatory grief should the nurse monitor the client for?
- A. Stating a fear of the future and unknown
- B. Engaging in periods of weeping or raging
- C. Expressing anger at the medical professionals
- D. Expressing a feeling of unreality and disbelief
- E. Expressing a desire to run away from the situation
- F. Stating that he knows all he needs to know about his condition
Correct Answer: A,B,C,D,E
Rationale: Anticipatory grief refers to the intellectual and emotional responses and behaviors by which individuals, families, or communities work through the process of modifying self-concept based on the perception of potential loss. Signs of anticipatory grief include fears of the future and the unknown, periods of weeping or raging, anger at medical professionals, a feeling of unreality and disbelief, a desire to run away from the situation, feelings of emptiness or of being lost, a sense of being numb and fatigued, a need to oversee every detail of care, pronounced clinging to or dependency on other family members, and fear of going crazy. A statement by the client that he knows all he needs to know about his condition is not a sign of anticipatory grieving; it may indicate another client problem such as avoidance or fear.
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A client suffering from visual hallucinations calls the nurse to her room and says, 'You need to hurry up and kill all these bugs on the wall before they get on me.' Which response by the nurse is most appropriate?
- A. Why don't you lay down and take a nap?
- B. I don't see them. Can you show me where they are?
- C. I will call maintenance and have them come take care of this right away.
- D. I know the bugs seem real to you, but I don't see anything on the walls.
Correct Answer: D
Rationale: This response acknowledges the client's perception without reinforcing the hallucination, promoting trust and reality orientation.
The nurse on the cardiac unit notes that a client recovering from a myocardial infarction appears worried and irritable. The client says, 'I am worried about my business. I run a restaurant and am used to working 70 hours a week. I am worried about whether I will be able to handle the stress once I am back there.' Which response by the nurse is best?
- A. Give the client a list of complementary therapies related to relaxation and say, 'Pretend this is a menu. Which of these would you like to order for yourself?'
- B. You might find it interesting to attend the cardiac cooking class the dietitian gives before you are discharged.
- C. Who is supposed to be taking care of the restaurant while you are here in the hospital?
- D. Hand the client the television control and say, 'Sometimes when I have a lot on my mind, I watch a movie. It makes me feel better.'
Correct Answer: A
Rationale: Providing a list of relaxation therapies directly addresses the client’s stress concerns and empowers them to choose coping strategies, aligning with their expressed worries about returning to a high-stress job. Other options are less relevant to stress management.
A client with schizophrenia states to the nurse, 'I am a spy for the FBI. I am an eye, an eye in the sky.' Based on this information, the nurse knows that the client is exhibiting which abnormal thought process?
- A. Echolalia
- B. Word salad
- C. Clang associations
- D. Loosened associations
Correct Answer: C
Rationale: The repetition of words or phrases that are similar in sound and in no other way (rhyming) is one altered thought and language pattern seen in clients with schizophrenia. Clang associations often take the form of rhyming. Echolalia is the involuntary parrot-like repetition of words spoken by others. Word salad is the use of words with no apparent meaning attached to them or to their relationship to one another. Loosened associations occur when the individual speaks with frequent changes of subject and when the content is only obliquely related.
When planning for the care of the client who is dying of diagnosed cancer, one of the goals is that the client verbalizes her or his acceptance of impending death. Which client statement indicates to the nurse that this goal has been reached?
- A. I just want to live until my 100th birthday.
- B. I would like to have my family here when I die.
- C. I'll be ready to die when my children finish school.
- D. I want to go to my daughter's wedding. Then I'll be ready to die.
Correct Answer: B
Rationale: Acceptance is often characterized by plans for death. Often the client wants loved ones nearby. The remaining options all reflect the bargaining stage of coping during which the client tries to negotiate with her or his higher power or fate.
The nurse is obtaining a health history from an adolescent. Which statement by the adolescent indicates a need for follow-up assessment and intervention?
- A. When I get stressed out about school, I just like to be alone.
- B. I find myself very moody. I'm happy one minute and crying the next.
- C. I don't eat any fatty foods, and I've already lost 8 pounds in 2 weeks.
- D. I can't seem to wake up in the morning. I would sleep until noon if I could.
Correct Answer: C
Rationale: During the adolescent period, there is a heightened awareness of body image and peer pressure to go on excessively restrictive diets. The extreme limitation of omitting all fat in the diet and losing weight during a time of growth suggests inadequate nutrition and a possible eating disorder. The remaining options are normal behaviors or feelings that occur during adolescence.