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A nurse is caring for a client whose partner has recently died. The client states, 'I am learning how to pay my own bills.' The nurse should identify that the client is experiencing which of the following tasks in Worden’s Four Tasks of Grieving?
- A. Experiencing the pain of grief
- B. Finding an enduring connection while embarking on a new life
- C. Accepting the reality of the loss
- D. Adjusting to an environment without the deceased
Correct Answer: D
Rationale: The correct answer is D: Adjusting to an environment without the deceased. This task involves adapting to life without the presence of the deceased partner, such as taking on new responsibilities like paying bills. It signifies a significant step in the grieving process, as the individual begins to establish a new routine and sense of normalcy without their loved one.
Choice A (Experiencing the pain of grief) is not the correct answer because this task refers to acknowledging and processing the emotional pain associated with the loss, which is a different aspect of grieving.
Choice B (Finding an enduring connection while embarking on a new life) is not the correct answer as it involves integrating the memory and influence of the deceased into the individual's ongoing life, which is different from adjusting to the practical aspects of life without them.
Choice C (Accepting the reality of the loss) is not the correct answer as it pertains to coming to terms with the fact that the loved one has passed away, which is an important
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A nurse is caring for a client whose partner died 3 years ago and reports that they are still unable to accept the loss. The nurse should identify that the client has manifestations of which of the following types of grief?
- A. Uncomplicated grief
- B. Prolonged grief
- C. Anticipatory grief
- D. Disenfranchised grief
Correct Answer: B
Rationale: The correct answer is B: Prolonged grief. This is because the client is still struggling to accept the loss after 3 years, which is indicative of prolonged grief. Uncomplicated grief (Choice A) typically resolves within a reasonable timeframe. Anticipatory grief (Choice C) occurs before the actual loss. Disenfranchised grief (Choice D) is when the individual's grief is not openly acknowledged or socially supported. In this scenario, the client's grief extends beyond the normal grieving process, indicating prolonged grief.
A nurse is teaching a class about reducing the risk of medication errors. Which of the following information should the nurse include?
- A. Provide a dedicated area for the nurse to prepare medications
- B. Wait to document medications given to clients until the end of a shift
- C. Remove medications from automatic dispensing systems before they are reviewed by pharmacists
- D. Prepare medications for multiple clients at the same time
Correct Answer: A
Rationale: Correct Answer: A - Provide a dedicated area for the nurse to prepare medications.
Rationale: Providing a dedicated area for medication preparation helps reduce distractions and promotes focus, decreasing the likelihood of errors. This setup allows for organization and prevents cross-contamination. It also encourages proper storage and disposal of medications, fostering a safer environment for medication preparation.
Summary of Other Choices:
B: Waiting to document medications until the end of a shift can lead to errors in documentation and potential confusion. Real-time documentation is crucial for accuracy.
C: Removing medications from automatic dispensing systems before pharmacist review bypasses a critical safety check, increasing the risk of errors.
D: Preparing medications for multiple clients simultaneously can lead to mix-ups and errors, as it increases the chances of confusion and incorrect dosing.
A nurse is assessing a client for orthostatic hypotension. Which of the following actions should the nurse take first?
- A. Assist the client into a standing position
- B. Check the blood pressure with the client in a supine position
- C. Determine the client's blood pressure 1 min after each position change
- D. Place the client in a sitting position
Correct Answer: B
Rationale: The correct answer is B: Check the blood pressure with the client in a supine position. This is the first action the nurse should take because it establishes the baseline blood pressure of the client in a resting position. Orthostatic hypotension is characterized by a drop in blood pressure upon standing. By measuring the blood pressure in a supine position first, the nurse can accurately assess the extent of the blood pressure change when the client stands up.
Choices A, C, and D are incorrect because they involve positioning changes before establishing the baseline blood pressure. It is crucial to first determine the baseline blood pressure to accurately diagnose orthostatic hypotension. Choice A (Assist the client into a standing position) and D (Place the client in a sitting position) may exacerbate the client's symptoms if orthostatic hypotension is present. Choice C (Determine the client's blood pressure 1 min after each position change) is premature without knowing the baseline blood pressure.
A nurse opens a unit-dose of a prescribed medication prior to administering it to a client. After education, the client refuses to take the medication. Which of the following actions should the nurse take?
- A. Notify the facility’s ethics committee
- B. Return the opened medication to the medication cart
- C. Report the incident to the provider
- D. Fill out an incident report
Correct Answer: C
Rationale: The correct answer is C: Report the incident to the provider. The nurse should report the client's refusal to take the medication to the provider to ensure appropriate documentation and follow-up care. This step is crucial for the client's safety and well-being.
A: Notifying the ethics committee is not necessary in this situation as the provider should be the first point of contact.
B: Returning the opened medication to the cart is inappropriate and unsafe as it could lead to medication errors.
D: Filling out an incident report may be necessary, but reporting to the provider should be the immediate action.
In summary, option C is the correct choice as it prioritizes the client's care and ensures proper communication with the healthcare provider.
A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia?
- A. The client who has a nasogastric (NG) tube to suction
- B. The client who has a chest tube to water seal
- C. The client who has an indwelling urinary catheter to gravity drainage
- D. The client who has a tracheostomy tube attached to humidified oxygen
Correct Answer: A
Rationale: The correct answer is A: The client who has a nasogastric (NG) tube to suction. Suctioning through the NG tube can lead to loss of gastric contents, including potassium, which can result in hypokalemia. The other choices do not directly affect potassium levels. B: A chest tube to water seal is used to drain air or fluid from the pleural space, not likely to cause hypokalemia. C: An indwelling urinary catheter to gravity drainage does not impact potassium levels. D: A tracheostomy tube with humidified oxygen does not affect potassium levels. Therefore, the client with the NG tube to suction is at risk for hypokalemia due to potential potassium loss.