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","C","D"]
Explanation
Choice A Reason:
When providing client education about the medication, the nurse focuses on informing the client about the purpose, dosage, and potential side effects of the medication. This step is crucial for ensuring that the client understands their treatment plan and can adhere to it properly. However, this is not the appropriate time to compare the medication administration record (MAR) against the medication container. The comparison should be done during the actual medication administration process to prevent errors.
Choice B Reason:
At the client’s bedside before administering the medication, the nurse should compare the MAR against the medication container. This step is part of the “three checks” process, which helps ensure that the correct medication is given to the right patient at the right time. By verifying the medication at the bedside, the nurse can catch any discrepancies and prevent potential medication errors.
Choice C Reason:
Before selecting the medication container, the nurse should compare the MAR against the medication container. This is the first of the “three checks” and is essential for ensuring that the correct medication is selected from the storage area. This step helps prevent errors that could occur if the wrong medication is chosen.
Choice D Reason:
While removing medication from the container, the nurse should again compare the MAR against the medication container. This is the second of the “three checks” and serves as an additional safeguard to ensure that the correct medication is being prepared for administration. This step helps catch any errors that might have been missed during the initial selection.
Choice E Reason:
When documenting the medication administration, the nurse records the details of the medication given, including the time, dosage, and any observations. While accurate documentation is crucial for maintaining a complete medical record, this is not the appropriate time to compare the MAR against the medication container. The comparison should be done during the medication administration process to ensure accuracy.
Correct Answer is B
Explanation
Choice A: Bounding Pulses
Bounding pulses are typically associated with increased cardiac output or high blood pressure, rather than active bleeding. In the context of postoperative care, bounding pulses might indicate fluid overload or other cardiovascular issues, but they are not a primary sign of active bleeding.
Choice B: Restlessness
Restlessness is a common sign of hypovolemia, which can occur due to active bleeding. When a patient is losing blood, their body may respond with anxiety or restlessness as a result of decreased oxygen delivery to tissues and organs. This is a compensatory mechanism to maintain perfusion. Restlessness, along with other signs such as tachycardia and hypotension, can indicate significant blood loss and the need for immediate intervention.
Choice C: Warm Skin
Warm skin is generally not associated with active bleeding. In fact, patients who are actively bleeding may present with cool, clammy skin due to peripheral vasoconstriction as the body attempts to maintain core temperature and blood flow to vital organs. Warm skin might be observed in other conditions, such as fever or inflammation, but it is not a typical sign of active bleeding.
Choice D: Brisk Capillary Refill
Brisk capillary refill, which is a capillary refill time of less than 2 seconds, indicates good peripheral perfusion and is not a sign of active bleeding. In contrast, a delayed capillary refill time (greater than 2 seconds) can be a sign of poor perfusion, which might occur in the case of significant blood loss. Therefore, brisk capillary refill is not indicative of active bleeding.