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Which intervention will the nurse planning care for a patient with acute grief implement?a. Providing information about the grief process
- A. Providing information about the grief process.
- B. Suggesting utilization of community resources in a few weeks
- C. Encouraging dependence on the nurse for support
- D. Assessing for signs of complicated grief or depression
Correct Answer: A
Rationale: The correct answer is A because providing information about the grief process helps the patient understand their feelings and reactions, promoting emotional healing. Choice B is incorrect because suggesting community resources may not address the patient's immediate needs. Choice C is incorrect as encouraging dependence on the nurse may hinder the patient's ability to cope independently. Choice D is incorrect because assessing for complicated grief or depression is important but not the initial intervention in planning care for acute grief.
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Which remark by one of the grief support group members would the nurse interpret as indicating unresolved feelings of guilt?
- A. The Christmas season is always a sad time for me.
- B. I know that my husband had a good life.
- C. It seems I miss my son more as time goes on.
- D. I am still wishing I had gotten help to him sooner.
Correct Answer: D
Rationale: The correct answer is D because expressing a wish for getting help sooner implies a sense of responsibility and guilt for not doing so. This indicates unresolved feelings of guilt. Choice A refers to sadness during a specific time of the year, not guilt. Choice B reflects acceptance and closure. Choice C indicates a natural progression of grief, not necessarily guilt.
A 79-year-old white male tells a nurse, “I have felt very sad lately. I do not have much to live for. My family and friends are all dead, and my own health is failing.” The nurse should analyze this comment as:
- A. Normal pessimism of the elderly.
- B. A call for sympathy
- C. Evidence of risks for suicide.
- D. Normal grieving.
Correct Answer: C
Rationale: The correct answer is C: Evidence of risks for suicide. The statement contains indicators such as feeling very sad, lack of purpose, isolation, and declining health, which are red flags for suicide risk in older adults. It is crucial for healthcare providers to assess and intervene promptly in such cases to prevent harm. Choices A, B, and D are incorrect because they do not address the seriousness of the situation or the potential risk for self-harm.
Which behaviors are reflective of legitimate phases of a group’s development? Select all that apply.
- A. Stating the goals of the group
- B. Establishing who will assume the leadership role
- C. Inviting family members to attend and provide their input
- D. Feeling safe enough to discuss painful personal situations
Correct Answer: A
Rationale: The correct answer is A because stating the goals of the group is reflective of the forming stage where members clarify the purpose and direction. Choice B is incorrect as determining leadership roles typically occurs during the storming stage. Choice C is incorrect as involving family members is not part of the group development process. Choice D is incorrect as discussing personal situations usually happens during the norming or performing stages, not in the initial forming stage.
A newly admitted patient diagnosed with major depression has gained 20 pounds over a few months and has suicidal ideation. The patient has taken an antidepressant medication for 1 week without remission of symptoms. Select the priority nursing diagnosis.
- A. Imbalanced nutrition: more than body requirements.
- B. Chronic low self-esteem.
- C. Risk for suicide.
- D. Hopelessness.
Correct Answer: C
Rationale: The priority nursing diagnosis in this case is C: Risk for suicide. This is because the patient is exhibiting suicidal ideation, which poses an immediate threat to their safety and well-being. Suicidal ideation requires urgent intervention to ensure the patient's safety. The patient's major depression, weight gain, and lack of symptom remission from the antidepressant medication further emphasize the seriousness of the situation. Choices A, B, and D are not the priority in this scenario as they do not address the immediate risk of harm to the patient. Imbalanced nutrition and chronic low self-esteem are important concerns but do not take precedence over the risk of suicide. Hopelessness, while relevant, is not as urgent as addressing the immediate risk of suicide.
The nurse determines that a patient is showing a decline in explicit memory. Which characterizes such a deficiency?
- A. Inability to remember how to operate a common kitchen appliance
- B. Difficulty remembering the name of a place visited 20 years ago
- C. Being unsuccessful at retaining new information
- D. Forgetting the ingredients of a favorite recipe
Correct Answer: B
Rationale: The correct answer is B because difficulty remembering the name of a place visited 20 years ago is a specific example of explicit memory decline. Explicit memory refers to the ability to consciously recall past events, facts, or experiences. This choice directly relates to a long-term memory retrieval issue, which is a hallmark of explicit memory decline. Choices A, C, and D do not specifically address explicit memory decline but rather touch on different memory processes such as procedural memory (A), short-term memory (C), and semantic memory (D).