When a hospitalized patient dies, his wife stares blankly at the nurse and states, “It can’t be.” The nurse assesses this as indicating:

Correct Answer: A

Rationale: The wife's statement, "It can't be," indicates that she is experiencing shock and disbelief at the news of her husband's death. This response is common when individuals are faced with a sudden and unexpected loss. The wife's blank stare and statement suggest that she is struggling to accept the reality of the situation, which aligns with the symptoms of shock and disbelief.

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: 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: C

Rationale: The correct assessment to be made in this scenario is that the relationship is moving from the orientation phase to the working phase. In the orientation phase of the nurse-patient therapeutic relationship, the focus is on building rapport, establishing trust, and determining the patient's needs and goals. As the patient voluntarily expresses a desire to work on the issue of relationships, it indicates a transition to the working phase where the patient actively identifies problems to address and goals to achieve. This shift demonstrates progress in the therapeutic relationship as the patient is engaging in the therapeutic process and contributing to the agenda set for the appointment. It signifies a readiness for collaborative problem solving and intervention planning, emphasizing the importance of the patient's involvement in decision-making and goal-setting in the therapeutic process.

Correct Answer: C

Rationale: Identifying triggers for hallucinations is a key step in managing symptoms effectively

Correct Answer: C

Rationale: Self-harm in response to hallucinations reflects impaired ability to control impulses and respond safely to internal stimuli.

Correct Answer: C

Rationale: Successfully managing midlife transitions involves finding realistic and satisfying alternatives to earlier, unmet goals, demonstrating emotional growth and adaptability.

Correct Answer: D

Rationale: This statement is concerning because it suggests the teenager may still have access to dangerous means (in this case, a gun) and may not fully understand or take responsibility for the gravity of his previous suicidal attempt. The attachment to the gun is alarming.

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.