The nurse is interviewing a client who says. "Today is the two-month anniversary of my wife's death from cancer". Select the most therapeutic response by the nurse
"Would you like to discuss this with the doctor?"
"How long were you married?"
"What type of cancer did your wife have?"
"How does that make you feel?"
The Correct Answer is D
A) "Would you like to discuss this with the doctor?": This response may imply that the nurse is not equipped to handle the emotional aspect of the conversation, potentially minimizing the client's feelings and discouraging further sharing.
B) "How long were you married?": While this question seeks to gather more information, it does not directly address the client's emotional experience or feelings related to their wife's death, which is the primary concern in this context.
C) "What type of cancer did your wife have?": This question may shift the focus to medical details rather than the client's emotional state, which is crucial in a therapeutic conversation about grief and loss.
D) "How does that make you feel?": This response is the most therapeutic as it invites the client to express their emotions and thoughts about their loss. It acknowledges their pain and encourages them to explore their feelings, which is essential for processing grief.
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Correct Answer is D
Explanation
A) Safety issues with an unsupervised resident in the lounge area: While there could be safety concerns related to a resident being in a common area at night, the primary outcome expected from continued insomnia would more directly relate to the individual's functioning rather than immediate safety issues.
B) Onset of cardiac dysfunction: While chronic sleep disturbances can contribute to various health problems, including cardiovascular issues, the immediate outcome of insomnia is more likely to be seen in daily functioning rather than a direct onset of cardiac dysfunction.
C) Onset of new underdiagnosed health problems: While ongoing insomnia may exacerbate existing health issues or lead to new ones over time, the most immediate and observable outcome of insomnia would relate to how it affects daily functioning rather than the development of new health problems.
D) The ability to function during the day may be hindered by these episodes: Insomnia typically leads to increased fatigue, decreased alertness, and impaired cognitive function during the day. As a result, the resident's overall ability to engage in daily activities and interact socially may be significantly hindered by their lack of restorative sleep.
Correct Answer is B
Explanation
A) To establish a rapport with the client and family: While building rapport is an important aspect of the health assessment process, it is not the primary purpose. Establishing a trusting relationship can enhance communication and the quality of care, but the overarching goal of the assessment extends beyond interpersonal dynamics.
B) To establish a database against which subsequent assessments can be measured: This is the primary purpose of a health assessment. By collecting comprehensive baseline data regarding a client's health status, the nurse creates a reference point for future evaluations. This allows for the monitoring of changes in the patient's condition over time, facilitating timely interventions when necessary.
C) To gather information for specialists to whom the client may be referred: Although gathering relevant information for potential referrals is beneficial, it is not the main purpose of the health assessment. The assessment primarily serves to inform the current healthcare team about the patient's status rather than focusing solely on future consultations.
D) To qualify the degree of pain the client may be experiencing: Assessing pain is an important component of a comprehensive health assessment, but it is just one aspect among many. The overall purpose of the health assessment encompasses a broader evaluation of physical, emotional, and social factors affecting the client's health.