A client told the nurse that even though his wife died 3 years ago, he continues to have dinner with her every Saturday night. He includes a table setting for her and prepares their "usual" steak dinner
He also lights a candle for her each week marking the time of her death. Which of the following nursing diagnoses will the nurse select during planning of care? 1. Death Anxiety
2. Risk for Bereavement
3. Ineffective Coping
4. Complicated Grieving
4. Complicated Grieving
Rationale:
The client exhibits complicated grieving through ritualistic behaviors, and his grieving has not come to the point of resolution after 3 years. Death anxiety is anxiety associated with the anticipation of death. The client is able to perform tasks to care for himself, but he has gone beyond ineffective coping to the dysfunctional. Bereavement is a state of loss that is transient and is not a nursing diagnosis.
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What should the nurse do when suspecting a co-worker of abusing drugs while at work?
a. Confront the abuser b. Report observations to a supervisor c. Call the state board of nursing d. Discuss the problem with another co-worker
A client with Bell palsy is ready for discharge. The nurse plans to have the client return-demonstrate which self-care action prior to discharge?
1. Skin care 2. Instilling eyedrops 3. Self-catheterization 4. Administering subcutaneous medications
A 56-year-old man is hospitalized because of poorly controlled diabetes and a leg ulcer that developed as a complication of diabetes. He is awake, alert, and oriented but fatigued and in need of wound care
In the hospital, he was placed on insulin and started on a variety of oral medications. He is learning how to check his blood sugar and administer insulin. He has never given himself insulin and he does not understand how to interpret his blood sugar readings. The physician has prescribed discharge from the hospital with home health follow-up. Is this an appropriate referral? a. Yes; the patient is in need of skilled services and, therefore, eligible for home care services. b. Yes; the patient has been unable to control his diabetes, is noncompliant, and needs to be monitored. c. No; the patient should remain hospitalized; he has too many needs for home care services. d. No; the patient is relatively young and oriented; he should be able to provide his own care.
When a client who routinely takes the herb St. John's Wort (SJW) shares that their "hay fever is really bad right now," the nurse initially:
a. notifies the primary care provider that the client has been self-medicating for hay fever b. compares the client's current blood pressure to his/her baseline blood pressure c. stresses the need to avoid over-the-counter (OTC) medications containing monoamines d. suggests that the client stop taking the herb until the hay fever has improved