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The nurse is caring for a depressed, withdrawn client who was responsible for an automobile accident that recently resulted in the death of a child. What is the nurse's initial action?
- A. Allow the client to have some time alone to grieve over the loss.
- B. Reinforce to the client that the child's death was a result of an accident.
- C. Communicate in a manner that acknowledges and respects the client's depressed state.
- D. Inform the primary health care provider of the client's possible need for medication to cope.
Correct Answer: C
Rationale: The nurse's initial intervention is to encourage the client to express feelings, which is facilitated by establishing a nurse-client relationship that is based upon respect. The correct option validates the perception that the client is depressed. This action also allows the nurse to assess the situation. Options 1, 2, and 4 address interventions before assessing the situation and identifying the client's actual needs.
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The nurse is interacting with the family of a client who is unconscious as a result of a head injury. Which approach should the nurse use to help the family cope with their concerns?
- A. Explain equipment and procedures on an ongoing basis.
- B. Discuss displaying their grief only when not in the room with the client.
- C. Discourage them from touching the client in order to minimize stimulation.
- D. Explain that they need their rest so they should adhere to regular visiting hours.
Correct Answer: A
Rationale: Families often need assistance to cope with the sudden severe illness of a loved one. The nurse should explain all equipment, treatments, and procedures, and he or she should supplement or reinforce the information given by the primary health care provider. Displaying grief is a normal process and should not be discouraged. The family should be encouraged to touch and speak to the client and become involved in the client's care in some way if they are comfortable with doing so. The nurse should allow the family to stay with the client whenever possible. This is important for both the client and the family.
A stillborn baby was delivered a few hours ago. After the birth, the family has remained together, holding and touching the baby. The registered nurse is orienting a new nurse, and has provided education on how to communicate with the family. Which statement by the new nurse indicates that teaching has been effective?
- A. How can I assist you with ways to remember your baby?'
- B. You seem upset. Do you think a tranquilizer would help?'
- C. I feel so bad. I don't understand why this happened either.'
- D. I can allow another 15 minutes together for you to grieve.'
Correct Answer: A
Rationale: Nurses should be able to explore measures that assist the family with creating memories of the infant so that the existence of the child is confirmed, and the parents can complete the grieving process. The correct option identifies this measure and also demonstrates a caring and empathetic client-focused response while providing the family with the option to express their needs. Option 2 devalues the parents' feelings and is inappropriate. Option 3 is inappropriate and reflects a lack of knowledge on the nurse's part. Option 4 appears that the nurse is uncaring.
The nurse cared for a client who died a few minutes ago. Which event supports the nurse's belief that the client died with dignity?
- A. The family thanks the nurse for facilitating such a peaceful death.
- B. The nurse states that it is difficult to give that kind of care to a dying client.
- C. The primary health care provider acknowledges that all of the prescriptions were carried out.
- D. The nurse kept the client's last hours comfortable with increasing doses of pain medication.
Correct Answer: A
Rationale: The family response is an external perception, and it is extremely important. Families derive a great deal of comfort from knowing that their loved one received the best care possible. The correct option provides external validation that the client received comprehensive, quality care. Option 2 focuses on the feelings of the nurse, who may be expressing his or her own anxiety. Option 3 focuses on the provider's prescriptions rather than client care. Option 4 reflects on only one aspect of the care of a dying client.
The nurse admits a client who is demonstrating right-sided weakness, aphasia, and urinary incontinence. The woman's daughter states, 'If this is a stroke, it's the kiss of death.' What initial response should the nurse make?
- A. Why would you think like that?'
- B. You feel your mother is dying?'
- C. These symptoms are reversible.'
- D. A stroke is not the kiss of death.'
Correct Answer: B
Rationale: Option 2 allows the daughter to verbalize her feelings, begin coping, and adapt to what is happening. By restating, the nurse seeks clarification of the daughter's feelings and offers information that potentially helps ease some of the fears and concerns related to the client's condition and prognosis. Option 1 is a disapproving comment that is likely to interfere with communication. Option 3 is potentially misleading and offers false hope. The nurse could reflect back the statement in option 4 to the daughter to promote communication. However, as it stands, option 4 is a barrier to communication that contradicts the daughter's feelings.
Shortly after a client dies, the nurse asks the family about funeral arrangements. When the family refuses to discuss the issue, which intervention by the nurse is appropriate for their stage of grief?
- A. Displaying acceptance of the family's issues
- B. Providing information about funerals in general
- C. Probing for information about funeral arrangements
- D. Asking the family if they would like time alone with the client
Correct Answer: D
Rationale: The family is exhibiting the first stage of grief: denial. By asking the family if they would like time alone with the client, the nurse supports the family's feelings and allows the family to process the death. Option 1 is a suitable intervention for the acceptance or reorganization and restitution stage of grief. Eliminate options 2 and 3 because they are not appropriate at this time since the family has indicated their desire not to discuss funeral arrangements.