A nurse in a mental health clinic is caring for a client who is grieving.
Nurses' Notes
1000:
Client presents to the mental health clinic and is tearful and angry recently experienced the loss of a child due to illness. Information provided to client about group therapy and individual therapy.
1100:
Client is continuing to sob and states, "I can't go on living without my child." Current list of home medications reviewed. Client states they have not been taking the prescribed medication "because it will not help."
1300:
Client spoke in group therapy session regarding feelings and prescribed treatment. Acknowledges the role of the therapist and expectations of support group, yet confides, "My anger and sadness are still very
Medication Administration
1000:
Sertraline 100 mg PO BID
Vital Signs
1015:
Temperature 36.8°C (98.4° F)
Heart rate 85/min
Respiratory rate 15/min
BP 147/86 mm Hg
Oxygen saturation 99%
A nurse is caring for a client who is grieving. Which of the following findings should the nurse identify as a priority to address? Select all that apply.
Statement regarding outlook on living
Statement related to feelings of sadness and anger.
Knowledge of expectations during group meetings.
Awareness of the therapist's role.
Statement related to use of pharmacological interventions.
Correct Answer : A,B,E
Rationales:
A. The client's statement, "I can't go on living without my child," indicates a potentially serious risk to their safety and well-being. This statement suggests that the client may be experiencing suicidal ideation or extreme despair, which requires immediate attention and intervention.
B. While sadness and anger are expected components of grief, the intensity of these feelings and their persistence need to be assessed for any signs of complicated grief or potential for self-harm. Addressing these emotions is critical to ensuring the client’s safety and providing appropriate support.
C. While understanding the expectations during group meetings is important for therapy, it is not as immediately critical as addressing the client's statements about their outlook on living and their medication adherence.
D. Knowledge about the therapist’s role is important for therapeutic alliance, but it is less urgent compared to addressing the client’s potentially dangerous outlook on living and their medication issues.
E. The client’s refusal to take the prescribed medication, with the belief that it "will not help," indicates a possible issue with medication adherence or effectiveness. This needs to be addressed to ensure that the client is receiving appropriate treatment for their mental health needs.
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View Related questions
Correct Answer is C
Explanation
Rationale:
A. Somatic symptom disorder involves physical symptoms without a clear medical cause, but the client's intention to be the center of attention is more characteristic of factitious disorder.
B. Functional neurological symptom disorder involves neurological symptoms with no identifiable neurological basis, which does not align with the client’s motivations.
C. Factitious disorder involves the intentional production of symptoms to assume the sick role and gain attention, which aligns with the client's desire to be the center of a dramatic medical situation.
D. Illness anxiety disorder involves preoccupation with having a serious illness despite a lack of symptoms but does not involve intentionally causing harm.
Correct Answer is B
Explanation
Rationale:
A. While inappropriate clothing might indicate a need for assessment of the client’s awareness or physical comfort, it is not as immediate a concern as the client's behavior.
B. The comment to the nurse is concerning as it may indicate disorganized thinking or potential for inappropriate behavior, which requires immediate attention for safety and therapeutic intervention.
C. A heart rate of 102/min is slightly elevated but not the most urgent issue compared to the client's behavior.
D. Elevated blood pressure should be monitored, but the priority is the client’s inappropriate behavior, which may affect safety.