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
Allowing the client to hear running water while attempting to void can sometimes help stimulate urination through the power of suggestion. This method is non-invasive and can be effective for some patients. However, it may not be sufficient for a client who is 6 hours postoperative and experiencing significant difficulty voiding. In such cases, more direct intervention may be necessary to prevent complications like bladder distension or urinary retention.
Choice B Reason
Encouraging fluid intake up to 1,000 mL daily is generally good advice for maintaining hydration and promoting urinary function. However, in the immediate postoperative period, especially within the first 6 hours, the focus should be on addressing the acute issue of urinary retention. Increasing fluid intake alone may not resolve the problem and could potentially exacerbate bladder distension if the client is unable to void.
Choice C Reason
Providing the client a bedpan while lying supine is a practical approach to assist with urination, especially if the client is unable to get out of bed. However, the supine position is not the most conducive for voiding, as it can make it more difficult for the bladder to empty completely. This method might not be effective for a client experiencing significant difficulty voiding postoperatively.
Choice D Reason
Inserting an indwelling urinary catheter and connecting it to gravity drainage is the most appropriate action for a client who is 6 hours postoperative and having difficulty voiding. This intervention directly addresses the issue of urinary retention by ensuring that the bladder is emptied, thereby preventing complications such as bladder distension, urinary tract infections, and potential kidney damage. It is a standard practice in postoperative care when less invasive methods are ineffective.
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.
