The elderly wife of a hospice client has reported experiencing difficulty sleeping and a decreased appetite. The priority nursing diagnosis most likely to apply is:
1. Grieving.
2. Fear.
3. Risk for Caregiver Role Strain.
4. Interrupted Family Process.
3
Rationale: The client might be grieving; however, this is not the priority diagnosis.
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A nurse has made a referral to a grief support group, knowing that many individuals find these both comforting and beneficial after the death of a loved one. What is the most important accomplishment available by attending a grief support group?
A) Providing a framework for incorporating the old life into the new life B) Normalizing adaptation to a continuation of the old life C) Aiding in adjusting to using old, familiar social skills D) Normalization of feelings and experiences
A nurse is caring for a patient with severe hemolytic jaundice. Laboratory tests show free bilirubin to be 24 mg/dL. For what complication is this patient at risk?
A) Chronic jaundice B) Pigment stones in portal circulation C) Central nervous system damage D) Hepatomegaly
In order to help patients manage discomfort and pain during labor, nurses should be aware that
a. The predominant pain of the first stage of labor is the visceral pain located in the lower portion of the abdomen. b. Somatic pain is the extreme discomfort between contractions. c. The somatic pain of the second stage of labor is more generalized and related to fatigue. d. Pain during the third stage is a somewhat milder version of the second stage.
A nurse is working with a client who has a disfigured face and who is undergoing a series of reconstructive operations. The nurse has formulated the diagnosis: Disturbed Body Image related to perceived disfigurement as a primary problem
The least helpful intervention by the nurse would be to a. present reality in a kind and compassionate manner. b. refer the client to a licensed aesthetician to help with makeup. c. say "I know how you feel" while sitting with the client. d. tell the client s/he has to look in a mirror to get used to the facial appearance.