A nurse assesses a woman whose husband died 13 months ago. She isolates herself, screams at her deceased spouse, and is increasingly restless. According to Bowlby, this widow is in which stage of the grieving process?
1. Stage I: Numbness or protest
2. Stage II: Disequilibrium
3. Stage III: Disorganization and despair
4. Stage IV: Reorganization
3
Rationale: The nurse should identify that this client is in the third stage of Bowlby's grief process, called disorganization and despair. This stage is characterized by feelings of despair in response to the realization that the loss has occurred. The individual experiences helplessness, fear, and hopelessness. Perceptions of visualizing or being in the presence of the lost one may occur.
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A child is admitted to the hospital and diagnosed with aplastic anemia. The parents ask the nurse what aplastic anemia is. Which would be the best description of aplastic anemia?
1. Causes a proliferation of white blood cells 2. Is characterized by abnormally shaped red blood cells 3. Is characterized by failure of the bone marrow to produce adequate numbers of cells 4. Is a disorder that occurs following a viral illness
The client with a chronic illness asks the nurse what a "living will" is. The nurse's best response explains that this form leaves instructions about:
1. What treatments to omit if one is unable to make these decisions. 2. Who is to make decisions if one is unable to make decisions. 3. Who is to inherit property and belongings after one has died. 4. How the costs of medical care are to be paid after one's death.
The nurse is caring for a patient who is at risk for fluid overload as a result of a history of congestive heart failure. Which intervention will the nurse teach the patient to perform at home to monitor fluid balance?
a. "Check to make sure that your urine is a bright yellow color." b. "Weigh yourself every morning before breakfast." c. "Count your heart rate every evening before you go to bed." d. "Drink plain water rather than soda, coffee, or fruit juice."
The nurse is caring for an older client that states, "I am not taking this medication anymore, and I am tired of being here." Which is the best action for the nurse to take?
1. Contact the client's family. 2. Discuss the therapeutic action of the medication. 3. Remind the client about their agreement for treatment. 4. Inform the client of their right to leave the facility AMA.