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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is C
Explanation
Choice A Reason
Increased heart rate during physical activity can be a common finding in clients who have been on bed rest for an extended period. This is due to deconditioning of the cardiovascular system. While it is important to monitor and address, it is not the most immediate concern compared to other potential complications.
Choice B Reason
Loss of appetite is another common issue in clients who have been on prolonged bed rest. It can lead to nutritional deficiencies and weight loss, which are significant concerns. However, it is not as urgent as other findings that might indicate more acute complications.
Choice C Reason
Left lower extremity tenderness is the most critical finding and should be identified as the priority. This symptom can indicate deep vein thrombosis (DVT), a serious condition that can lead to life-threatening complications such as pulmonary embolism if not promptly addressed. DVT is a common risk for clients who have been immobile for extended periods, making it a top priority for immediate
intervention.
Choice D Reason
Musculoskeletal weakness is expected in clients who have been on bed rest for several weeks. It results from muscle atrophy and deconditioning. While it is an important issue to address through rehabilitation and physical therapy, it does not pose an immediate threat to the client’s life compared to the risk of DVT.
Correct Answer is C
Explanation
Choice A Reason:
Rotating the swab over necrotic tissue is not recommended because necrotic tissue does not provide an accurate representation of the microorganisms present in the wound. Necrotic tissue is dead tissue, and culturing it can lead to misleading results, as it may not reflect the current state of infection or the microorganisms causing the infection.
Choice B Reason:
Obtaining the sample from the outer edge of the wound is also not ideal. The outer edge of the wound may be contaminated with skin flora or other external contaminants, which can lead to inaccurate culture results. The sample should be taken from clean, viable tissue within the wound bed to ensure accurate identification of the microorganisms present.
Choice C Reason:
Applying sterile gloves to remove the outer dressing is the correct action. This step is crucial to maintain aseptic technique and prevent contamination of the wound and the specimen. Sterile gloves help ensure that the nurse does not introduce any external microorganisms into the wound while handling the dressing.
Choice D Reason:
Crushing the transport medium after obtaining the specimen is a necessary step to activate the medium and preserve the specimen during transport to the laboratory. However, this step comes after the specimen has been collected and does not directly relate to the technique of obtaining the specimen.
