Devastated by a divorce from an abusive husband, a wife completes grief counseling. Which statement by the wife would indicate to a nurse that the client is in the acceptance stage of grief?

Correct Answer: C

Rationale: The correct answer is C: "Yes, it was a difficult relationship, but I think I have learned from the experience." This statement indicates acceptance because the wife acknowledges the difficulty of the relationship but also expresses personal growth and learning from it. Acceptance stage involves coming to terms with the reality of the situation and finding meaning or lessons in the experience. A: "If only we could have tried again, things might have worked out." - This statement suggests bargaining, which is a stage before acceptance where the individual is trying to negotiate or change the outcome. B: "I am so mad that the children and I had to put up with him as long as we did." - This statement reflects anger, another stage of grief where the individual may feel resentful or frustrated about the situation. D: "I have a difficult time getting out of bed most days." - This statement indicates symptoms of depression or denial, which are common in earlier stages of grief, not acceptance.

Correct Answer: B

Rationale: Correct Answer: B - Verify patient identification and informed consent Rationale: 1. Ensures the right patient is undergoing the intended procedure. 2. Validates patient's understanding and agreement to the procedure. 3. Legal and ethical requirement to prevent errors and ensure patient safety. Summary: A: Important but assessing consciousness can be done after patient identification. C: Vital signs are crucial but can be assessed after verifying patient identity. D: Checking for personal items is important but secondary to confirming patient identity.

Correct Answer: C

Rationale: The correct answer is C: Wash hands. This is the first step in any nursing intervention to prevent infection. Washing hands before examining the incision wound and changing the dressing helps reduce the risk of introducing harmful bacteria. By washing hands, the nurse maintains aseptic technique and minimizes the chance of contaminating the wound. Choice A is incorrect because observing the dressing and drainage comes after washing hands to ensure a clean environment. Choice B is unnecessary for a routine wound dressing change. Choice D is incorrect because requesting the client to expose the wound should only be done after ensuring proper hand hygiene.

Correct Answer: C

Rationale: The correct answer is C because allowing the client to walk relative to the Operating Room (OR) would increase the risk of falls, contradicting the goal of reducing patient harm. Walking near the OR could lead to accidents due to medical equipment, slippery floors, or unfamiliar surroundings. Assessing potential fall risks related to medications (choice A) is crucial for identifying and mitigating risks. Taking action through Incident Reports (choice B) helps address identified risks and improve patient safety. Assessing and reassessing individual fall risks (choice D) is essential for tailoring preventive measures to each patient's needs. In summary, allowing clients to walk near the OR poses a significant risk of falls and should be avoided.

Correct Answer: A

Rationale: The correct answer is A: Increased weight. After ileostomy, patients typically experience weight loss due to decreased absorption of nutrients. Irritation of skin around the stoma is expected due to frequent contact with stool. Liquid stool is common as the colon is bypassed, resulting in decreased water absorption. Establishment of regular bowel movement is also expected post-ileostomy once the intestinal tract adjusts. Therefore, increased weight is not expected due to decreased nutrient absorption.