Which of the following gives cues to the nurse that the patient may be grieving for loss?

Correct Answer: A

Rationale: A grieving individual may show a range of cues across different aspects of their life. Thoughts may include constant preoccupation with the loss, difficulties in concentrating, or intrusive thoughts. Feelings may involve sadness, anger, guilt, confusion, or relief. Behavioral cues may include changes in sleep patterns, appetite, energy levels, social withdrawal, or the use of substances. Physiologic complaints can manifest as headaches, stomach issues, fatigue, or other physical symptoms. Therefore, when a nurse observes cues related to thoughts, feelings, behavior, and physiologic complaints in a patient, it can suggest that the patient is grieving for a loss.

Correct Answer: A

Rationale: A safe patient environment should address the physical, emotional, and psychological well-being of the patient. While socio-economic needs are important for overall patient care, they are not directly related to creating a safe environment within a healthcare setting. Factors such as maintaining sanitation, meeting basic needs, and reducing physical hazards are crucial to ensuring the safety and well-being of patients. However, addressing socio-economic needs falls more within the realm of holistic patient care beyond just the physical safety aspect.

Correct Answer: A

Rationale: Difficulty of speaking and chewing is an indicator of cranial nerve involvement. Cranial nerves are responsible for controlling various functions of the head and neck, including speech and mastication. Impairment of cranial nerve function can lead to difficulty in these activities. In the context of the question, with the patient in the stroke unit, cranial nerve involvement can occur due to the stroke affecting the brain regions responsible for cranial nerve function. Loss of pain sensation, spastic paralysis of the extremities, and forgetfulness with syncope are not specific indicators of cranial nerve involvement in this scenario.

Correct Answer: B

Rationale: In order to understand and interpret a message accurately, it is essential to consider the context in which it was delivered. Context provides the necessary background information, setting, and circumstances that give meaning and relevance to the message being communicated. Without context, it can be challenging to fully grasp the intention and significance of the communication. While the other options (process, phrases and sentences, thoughts and feelings) play roles in communication, it is the context that ultimately helps to give meaning and context to the message being conveyed.

Correct Answer: C

Rationale: When discharging a suicidal patient who has been taking tricyclic antidepressant drugs, it is crucial for the nurse to evaluate the risk for suicide by overdose of the medication. Tricyclic antidepressants have a narrow therapeutic index, meaning that the difference between a therapeutic dose and a toxic dose can be quite small. This makes them particularly dangerous in cases of overdose, as they can lead to severe toxic effects, including cardiac arrhythmias, seizures, and death.