A nurse is caring for a client who was recently diagnosed with a terminal illness. The client tells the nurse, “I am looking forward to seeing my grandchildren grow up.” The nurse should identify that the client is experiencing which of the following stages of grief?
Denial
Anger
Bargaining
Acceptance
The Correct Answer is A
Choice A Reason:
Denial is the first stage of grief, where individuals refuse to accept the reality of their situation. In this case, the client is looking forward to a future event (seeing their grandchildren grow up) despite being diagnosed with a terminal illness. This indicates that the client is not acknowledging the severity of their condition and is instead holding onto a hopeful but unrealistic outcome. Denial serves as a defense mechanism to protect the individual from the immediate shock and pain of their diagnosis.
Choice B Reason:
Anger is the second stage of grief, characterized by feelings of frustration and helplessness. Individuals in this stage may direct their anger towards themselves, others, or the situation. The client’s statement does not reflect anger or frustration but rather an unrealistic hope for the future, which aligns more with denial than anger.
Choice C Reason:
Bargaining is the third stage of grief, where individuals attempt to negotiate or make deals to alter their situation. This stage often involves “if only” or “what if” statements as the person tries to regain control. The client’s statement does not indicate any form of negotiation or deal-making but rather a refusal to accept the reality of their terminal illness.
Choice D Reason:
Acceptance is the final stage of grief, where individuals come to terms with their situation and begin to plan for the future realistically5. In this stage, there is an acknowledgment of the loss and a gradual adjustment to the new reality. The client’s statement about looking forward to seeing their grandchildren grow up does not reflect acceptance but rather a denial of the terminal nature of their illness.
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Correct Answer is B
Explanation
Choice A: Seat the client in a chair for 30 minutes prior to applying the stockings.
Seating the client in a chair for 30 minutes before applying the stockings is not necessary. In fact, it is recommended to apply antiembolic stockings while the client is in a supine position to prevent blood from pooling in the legs. This ensures that the stockings fit properly and provide the intended compression to promote venous return.
Choice B: Measure the length of the client’s leg from the heel to the gluteal fold.
Measuring the length of the client’s leg from the heel to the gluteal fold is essential for ensuring the correct fit of knee-length antiembolic stockings. Proper measurement helps in selecting the right size, which is crucial for the stockings to be effective in preventing deep vein thrombosis (DVT) by promoting blood circulation. Incorrectly sized stockings may either be too tight, causing discomfort and impaired circulation, or too loose, failing to provide adequate compression.
Choice C: Instruct the client to point their toes while applying the stockings.
Instructing the client to point their toes while applying the stockings is not a standard practice. Instead, the nurse should gather the stocking material and gently roll it over the foot and up the leg, ensuring it is evenly distributed and free of wrinkles. This method helps in applying the stockings smoothly and effectively without causing discomfort or improper fit.
Choice D: Roll the top of the client’s stockings down to just below the knee.
Rolling the top of the stockings down to just below the knee is incorrect and can lead to a tourniquet effect, which can impede blood flow and increase the risk of DVT. The stockings should be applied smoothly and should extend to their full length without being rolled down to ensure proper compression and effectiveness.
Correct Answer is A
Explanation
Choice A reason:
A client who has new onset of dyspnea 24 hours after a total hip arthroplasty should be seen first. Dyspnea, or difficulty breathing, can be a sign of a serious complication such as a pulmonary embolism, which is a medical emergency. Pulmonary embolism is a blockage in one of the pulmonary arteries in the lungs, usually caused by blood clots that travel to the lungs from the legs or other parts of the body. This condition requires immediate assessment and intervention to prevent life-threatening consequences.
Choice B reason:
A client who has a urinary tract infection and low-grade fever is a concern, but it is not as urgent as the client with new onset dyspnea. Urinary tract infections (UTIs) are common and can be managed with antibiotics and supportive care. While a low-grade fever indicates an infection, it does not pose an immediate threat to the client’s life. The nurse should still address this client’s needs, but it can be done after attending to the more urgent case.
Choice C reason:
A client who has acute abdominal pain of 4 on a scale from 0 to 10 should be assessed, but it is not as critical as the client with new onset dyspnea. Acute abdominal pain can have various causes, some of which may require urgent attention, but a pain level of 4 indicates moderate pain. The nurse should evaluate this client to determine the cause of the pain and provide appropriate interventions, but it can be done after addressing the more urgent case.
Choice D reason:
A client who has pneumonia and an oxygen saturation of 96% is stable at the moment. Oxygen saturation levels above 95% are generally considered acceptable in pneumonia patients. While pneumonia requires monitoring and treatment, the client’s current oxygen saturation level indicates that they are not in immediate respiratory distress. The nurse should continue to monitor this client and provide necessary care, but it can be done after attending to the more urgent case.
