The nurse is caring for a client admitted for severe weight loss and depression. The client has recently experienced the loss of three close family members and has withdrawn from all social activities
In developing the plan of care, the nurse would correctly choose which of the following nursing diagnoses? 1. Powerlessness
2. Anxiety
3. Dysfunctional grieving
4. Spiritual distress
3
Rationale 1: Powerlessness refers to feelings of a loss of control with the situation.
Rationale 2: Anxiety infers feelings of apprehension.
Rationale 3: Clients experiencing tremendous loss often develop depression as part of their reaction to grief. However, this depression should also be seen with other stages of the grieving process such as denial, anger, bargaining, and acceptance. Clients remaining in one stage of the grieving process may not be progressing toward acceptance.
Rationale 4: Spiritual distress infers the client would be at odds with her feelings.
You might also like to view...
During a home visit, the nurse learns that a new mother is fatigued because the baby is not sleeping well. Which suggestion should the nurse make to help decrease this client's fatigue?
A) Advise the client to alternate night feedings with the baby's father to allow each parent to rest. B) Suggest that the client ask the neighbors to babysit one night a week. C) Ask the physician for medication to restore energy. D) Increase exercise time each week to promote energy.
The nurse is caring for a client who is experiencing anaphylactic shock following the administration of a medication. Which position is the most appropriate for the nurse to place the client based on this data?
A) Trendelenburg position B) Flat, with legs slightly elevated C) Supine position D) High Fowler position
A pregnant woman's diet history indicates that she likes the following list of foods. The nurse would encourage this woman to consume more of which food to increase her cal-cium intake?
a. Fresh apricots b. Canned clams c. Spaghetti with meat sauce d. Canned sardines
A patient applies a transdermal nitroglycerin patch at 0900. What additional instruction should be provided by the nurse regarding the patch?
a. "Leave the patch in place until the following morning, when a new patch will be applied." b. "Apply an additional patch if breakthrough anginal pain occurs." c. "Remove the patch at 9 PM." d. "Note the location of the patch, so that it can be reapplied in the same location to enhance absorption."