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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.

A.

Statement regarding outlook on living

B.

Statement related to feelings of sadness and anger.

C.

Knowledge of expectations during group meetings.

D.

Awareness of the therapist's role.

E.

Statement related to use of pharmacological interventions.

Question Solution

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.


View Related questions

Correct Answer is C

Explanation

Rationale:

A. The cortico-striato-thalamo-cortical circuit (CSTC) is primarily associated with obsessive-compulsive disorder (OCD) and does not directly relate to phobias.

B. While the CSTC circuit is involved in OCD, it is not specifically linked to the broader spectrum of fear responses.

C. The amygdala-centered (ACC) circuit is involved in the processing of fear and panic, making it directly associated with feelings of panic, which are common manifestations of anxiety disorders.

D. The amygdala does play a role in anxiety and apprehension, but it is more specifically tied to the acute panic responses.

Correct Answer is A

Explanation

Rationale:

A. Stopping the transfusion is the priority action as it is essential to prevent further potential adverse effects and initiate an investigation of a possible transfusion reaction.

B. Assessing the skin for a rash is important but secondary to stopping the transfusion.

C. Notifying the provider is necessary, but the immediate priority is to stop the transfusion.

D. Covering the client with a blanket does not address the potential severity of a transfusion reaction.