Correct Answer: A

Rationale: The patient whose 16-year-old daughter was raped and killed while going on an errand for the patient would be determined to be at highest risk for dysfunctional grief. This traumatic event involves sudden and violent loss of a child, which can lead to complicated or dysfunctional grief reactions. The circumstances of the death, involving violence, unexpectedness, and the close relationship with the deceased, can significantly impact the grieving process. The patient may struggle with intense emotions, guilt, anger, and unresolved trauma, making them more vulnerable to experiencing dysfunctional grief. It is essential for healthcare professionals to provide appropriate support and interventions to help the patient navigate through this complex grieving process.

Correct Answer: B

Rationale: Ativan and lorazepam are the same drug, so the patient is taking an excessive dose of lorazepam. This requires intervention by the nurse to prevent harm.

Correct Answer: A

Rationale: Boundaries define responsibilities and duties to one’s self in relation to others. Setting boundaries is essential in establishing a safe and professional therapeutic relationship between a nurse and a patient. These boundaries help to create a clear understanding of each person's roles and responsibilities within the relationship. Boundaries also help protect both the nurse and the patient from potential harm, maintain professionalism, and ensure effective communication and focus on the therapeutic goals. By defining these boundaries, the nurse can better maintain appropriate relationships with patients and avoid conflicts of interest or ethical dilemmas.

Correct Answer: C

Rationale: Each child will grieve in a unique way and on their own timetable. It is essential for the mother to acknowledge and understand that each of her children will process the loss of their dear aunt differently. Some children might show their emotions openly and seek comfort, while others might prefer to process their feelings more privately. By recognizing and respecting these individual differences, the mother can provide the necessary support tailored to each child's specific needs. This approach helps create a supportive environment where each child feels understood and cared for as they navigate their grief journey.

Correct Answer: B

Rationale: A nurse should maintain objectivity and conduct their own assessment, considering all sources of information.