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 D
Explanation
Choice A Reason:
Logrolling is a technique used to turn a patient while maintaining the alignment of the spine. It is particularly important for patients with spinal injuries or those who have undergone spinal surgery. While preventing friction is a benefit, the primary purpose of logrolling is to maintain spinal alignment and prevent further injury.
Choice B Reason:
Keeping the arms at the sides while logrolling is not a standard recommendation. In fact, it is often suggested that patients cross their arms over their chest to minimize lateral spinal displacement during the roll. This helps in maintaining the alignment of the spine and preventing any twisting or bending.
Choice C Reason:
The head of the bed should be flat during logrolling to ensure proper spinal alignment. Elevating the head of the bed can cause misalignment and increase the risk of injury. The bed should be positioned flat and at a comfortable working height for the caregivers performing the logroll.
Choice D Reason:
Logrolling is specifically designed to keep the spine in alignment. This technique involves turning the patient in one smooth motion without twisting or bending the body. It is crucial for patients with spinal injuries to prevent further damage and ensure safe repositioning.
Correct Answer is B
Explanation
Choice A Reason:
While it is important to monitor bowel movements, especially since opioids like morphine can cause constipation, this is not the immediate priority. Opioid-induced constipation is a common side effect due to decreased gastrointestinal motility. However, it does not pose an immediate life-threatening risk compared to respiratory depression.
Choice B Reason:
A respiratory rate of 7 breaths per minute is significantly below the normal range for adults, which is typically 12-20 breaths per minute. This indicates severe respiratory depression, a known and potentially fatal side effect of morphine. Immediate intervention is required to ensure the patient’s airway is maintained and to prevent respiratory arrest.
Choice C Reason:
Although the client reporting a pain level of 8 out of 10 indicates that the pain is not adequately controlled, this is not the most urgent concern compared to respiratory depression. Pain management is crucial, but ensuring the patient’s respiratory function takes precedence.
Choice D Reason:
A distended bladder can be a side effect of morphine due to urinary retention. While this needs to be addressed to prevent discomfort and potential complications, it is not as critical as managing a severely low respiratory rate.