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 reason:
Lowering the head of the client’s bed to 15 degrees can help facilitate the drainage of the NG tube. This position uses gravity to assist in the movement of gastric contents through the tube. However, it is not the most effective method to address the issue of the NG tube not draining. This action might be more appropriate for other clinical scenarios, such as preventing aspiration, but it is not the primary intervention for a non-draining NG tube.
Choice B reason:
Injecting 10 mL of air into the vent lumen is a common technique used to clear an obstruction in the NG tube. This action can help dislodge any blockages that may be preventing the tube from draining properly. By injecting air, the nurse can ensure that the tube is patent and functioning correctly. This method is often recommended in clinical guidelines for managing NG tube blockages.
Choice C reason:
Placing the NG tube to high suction is not recommended as it can cause damage to the gastric mucosa and lead to complications such as bleeding or ulceration. High suction can create excessive negative pressure, which can harm the delicate tissues of the stomach lining. Therefore, this action is not appropriate for managing a non-draining NG tube and should be avoided.
Choice D reason:
Connecting the air vent to the suction is incorrect and can lead to malfunction of the NG tube. The air vent, also known as the pigtail, is designed to allow air to enter the stomach and prevent the tube from adhering to the gastric mucosa. Connecting it to suction would negate its purpose and could cause the tube to become blocked or damaged. This action is not recommended in any clinical guidelines for NG tube management.
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.