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 ["B","D","E","F"]
Explanation
Rationale:
A. The ECG shows persistent sinus bradycardia on both December 1 and December 15. While sinus bradycardia is common in anorexia nervosa, its persistence may not necessarily reflect a therapeutic response.
B. The respiratory rate improved from 24/min to 20/min and the respirations are described as even and unlabored on December 15. This indicates a positive response to treatment.
C. The temperature data for December 15 is not provided. However, an increase toward normal temperature would indicate a therapeutic response, but without this data, we cannot confirm.
D. The weight increased from 34.5 kg (76 lb) to 37.2 kg (82 lb), which is a significant therapeutic improvement, reflecting progress in treatment.
E. The sodium level improved from 128 mEq/L to 130 mEq/L. Although the level is still slightly below normal, the upward trend indicates improvement.
F. The creatinine level decreased from 1.2 mg/dL to 0.9 mg/dL, showing improvement in kidney function and response to treatment.
Correct Answer is C, A, D, E, B
Explanation
Rationale:
Murophobia: Client A's extreme fear of mice indicates a specific phobia. In this case, it is specifically referred to as murophobia.
Separation anxiety: Client B's distress over their partner's absence aligns with separation anxiety.
Mutism: Client C's continued silence in group sessions suggests mutism, a form of non-verbal behavior often associated with anxiety or trauma.
Body dysmorphism: Client D's behavior of wearing boots due to negative feelings about their feet reflects body dysmorphic disorder, where a person has a distorted view of their body.
Trichotillomania: Client E’s behavior of pulling out their hair after twisting it indicates trichotillomania, a disorder characterized by compulsive hair pulling.