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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View Related questions
Correct Answer is A
Explanation
Choice A Reason
Waiting 5 minutes between the administration of each medication is the most appropriate action. This allows each medication to be absorbed properly without being washed away by the subsequent drops. Adequate absorption ensures that each medication can exert its therapeutic effect effectively.
Choice B Reason
Asking the client to close their eyes tightly after instilling each medication is not recommended. This action can force the medication out of the eye, reducing its effectiveness. Instead, clients should be advised to close their eyes gently to allow the medication to spread evenly across the eye surface.
Choice C Reason
Holding the dropper 3 cm (1.2 in) away from the client’s eye is too far. The recommended distance is about 1 to 2 cm (0.4 to 0.8 in) to ensure that the drops are accurately placed in the conjunctival sac without touching the eye or eyelashes, which could cause contamination.
Choice D Reason
Massaging the client’s eyelids for 20 seconds after instillation is not a standard practice for administering ophthalmic drops. This action could potentially irritate the eye or cause discomfort. Instead, gentle pressure can be applied to the inner corner of the eye (nasolacrimal duct) for a few seconds to prevent the medication from draining into the tear duct.
Correct Answer is D
Explanation
Choice A Reason:
The pad of the thumb is not typically recommended for capillary blood glucose testing. While it is possible to obtain a blood sample from the thumb, it is less commonly used due to the thickness of the skin and the presence of more nerve endings, which can make the procedure more painful. Fingertips, especially the sides of the fingers, are preferred because they have a rich supply of capillaries and are less painful.
Choice B Reason:
The pinna of the ear is not a standard site for capillary blood glucose testing. This area is not commonly used because it is less accessible and may not provide a reliable blood sample. The fingertips are more practical and provide consistent results due to their capillary density.
Choice C Reason:
The pad of the big toe is also not a common site for capillary blood glucose testing. Similar to the thumb, the skin on the toes is thicker and may be more painful to puncture. Additionally, the toes are less convenient and hygienic for frequent testing compared to the fingers.
Choice D Reason:
The side of the ring finger is one of the most recommended sites for capillary blood glucose testing. This area is preferred because it has a good capillary supply, making it easier to obtain an adequate blood sample. Additionally, the sides of the fingers are less sensitive than the pads, reducing discomfort during the procedure. Using the sides of the fingers also helps to avoid the more sensitive central part of the fingertip.
