Saunders NCLEX questions

The nurse is assessing a client's postoperative pain using the PQRSTU method. Using this method, which questions would the nurse ask the client?

The PQRSTU method is one method of assessing pain. With this method, the nurse asks about the following: Precipitating factors (option 6); Quality of the pain (option 3); Region or Radiation of the pain (option 1); Severity of the pain; Timing of the pain (continuous or intermittent); and How the pain affects you (option 4). Options 2 and 5 may be questions that would be asked; however, these are not a part of the PQRSTU method.

The nurse is preparing to administer furosemide (Lasix) to a client with a diagnosis of heart failure. Which is the most important laboratory test result for the nurse to check before administering this medication?

1-Blood urea nitrogen
2-Cholesterol level
3-Potassium level
4-Creatinine level

Furosemide is a loop diuretic. The medication causes a decrease in the client's electrolytes, especially potassium, sodium, and chloride. Administering furosemide to a client with low electrolyte levels could precipitate ventricular dysrhythmias. Options 1 and 4 reflect renal function. The cholesterol level is unrelated to the administration of this medication.

A nurse caring for a client with a diagnosis of gastrointestinal (GI) bleeding reviews the client's laboratory results and notes a hematocrit level of 30%. Which action should the nurse take?

1-Report the abnormally low level.
2-Report the abnormally high level.
3-Inform the client that the laboratory result is normal.
4-Place the normal report in the client's medical record.

1-Report the abnormally low level.

The normal hematocrit level in a male ranges from 42% to 52%, and 35% to 47 % in a female, depending on age. A hematocrit level of 30% is a low level and would be reported to the health care provider because it indicates blood loss; therefore options 2, 3, and 4 are incorrect.

A nurse provides dietary instructions to a client who will be taking warfarin sodium (Coumadin). The nurse should tell the client to avoid which food item?

1-Grapes
2-Spinach
3-Watermelon
4-Cottage cheese

2-Spinach

Warfarin sodium is an anticoagulant. Anticoagulant medications act by antagonizing the action of vitamin K, which is needed for clotting. When a client is taking an anticoagulant, foods high in vitamin K often are omitted from the diet. Vitamin K-rich foods include green leafy vegetables, fish, liver, coffee, and tea.

A client who has been receiving total parenteral nutrition (TPN) by way of a central venous access device complains of chest pain and dyspnea. The nurse quickly assesses the client's vital signs and notes that the pulse rate has increased and the blood pressure has dropped. The nurse determines that the client is most likely experiencing which problem?

1-Sepsis
2-Air embolism
3-Fluid overload
4-Fluid imbalance

2-Air embolism

The signs and symptoms of air embolism include chest pain, dyspnea, hypoxia, anxiety, tachycardia, and hypotension. The nurse also may hear a loud churning sound over the pericardium on auscultation of the client's chest. The signs and symptoms of sepsis include fever, chills, and general malaise. Fluid overload causes increased intravascular volume, which increases the blood pressure and the pulse rate as the heart tries to pump the extra fluid volume. Fluid overload also causes neck vein distention and shifting of fluid into the alveoli, resulting in lung crackles. The signs and symptoms of a fluid imbalance depend on the type of imbalance the client is experiencing.

A client who is receiving intravenous (IV) fluid therapy complains of burning and a feeling of tightness at the IV insertion site. On assessment, the nurse detects coolness and swelling at the site and notes that the IV rate has slowed. The nurse determines that which complication has occurred?

1-Infection
2-Phlebitis
3-Infiltration
4-Thrombosis

An infiltrated IV line is one that has dislodged from the vein and is lying in subcutaneous tissue. Pallor, coolness, and swelling at the IV site result when IV fluid is deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of IV solution will slow down or stop. The corrective action is to remove the catheter and start a new IV line at another site. The conditions identified in options 1, 2, and 4 are likely to be accompanied by warmth at the site, not coolness.

A nurse provides instructions to a preoperative client about the use of an incentive spirometer. The nurse determines that the client needs further instruction if the client indicates that he or she will take which action?

1-Sit upright when using the device.
2-Inhale slowly, maintaining a constant flow.
3-Place the lips completely over the mouthpiece.
4-After maximal inspiration, hold the breath for 10 seconds and then exhale.

4-After maximal inspiration, hold the breath for 10 seconds and then exhale.

For optimal lung expansion with the incentive spirometer, the client should assume a semi-Fowler's or high Fowler's position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. When maximal inspiration is reached, the client should hold the breath for 2 or 3 seconds and then exhale slowly

The nurse is monitoring a client who has a closed chest tube drainage system. The nurse notes fluctuation of the fluid level in the water-seal chamber during inspiration and expiration. On the basis of this finding, the nurse should make which interpretation?

1-There is a leak in the system.
2-The chest tube is functioning as expected.
3-The amount of suction needs to be decreased.
4-The occlusive dressing at the insertion site needs reinforcement.

2-The chest tube is functioning as expected.

The presence of fluctuation of the fluid level in the water-seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, if the suction is not working properly, or if the lung has re-expanded. Options 1, 3, and 4 are incorrect interpretations of the finding. An air leak may cause excessive bubbling in the water seal chamber. Excessive and vigorous bubbling in the suction control chamber may indicate that the amount of suction needs to be decreased. The status of the dressing is not specifically related to the presence of fluctuation of the fluid level in the water-seal chamber

A nurse is providing morning care to a client who has a closed chest tube drainage system to treat a pneumothorax. When the nurse turns the client to the side, the chest tube is accidentally dislodged from the chest. The nurse immediately applies sterile gauze over the chest tube insertion site. Which is the nurse's next action?

1-Call the health care provider.
2-Replace the chest tube system.
3-Obtain a pulse oximetry reading.
4-Place the client in a Trendelenburg position

1-Call the health care provider.

If the chest drainage system is dislodged from the insertion site, the nurse immediately applies sterile gauze over the site and calls the health care provider. The nurse would maintain the client in an upright position. A new chest tube system may be attached if the tube requires insertion, but this would not be the next action. Pulse oximetry readings would assist in determining the client's respiratory status, but the priority action would be to call the health care provider in this emergency situation.

A nurse reviews the medication history of a client and notes that the client is taking leflunomide (Arava). During assessment of the client, the nurse should ask which question to determine the effectiveness of this medication?

1-"Do you have any joint pain?"
2-"Are you having any diarrhea?"
3-"Are you experiencing heartburn?"
4-"Do you have frequent headaches?"

1-"Do you have any joint pain?"

Leflunomide is an immunomodulatory agent and has an anti-inflammatory action. The medication provides symptomatic relief of rheumatoid arthritis. Diarrhea can occur as a side effect of the medication. Options 2, 3, and 4 are unrelated to the action, use, or effectiveness of the medication.

A nurse is checking lochia discharge in a woman in the immediate postpartum period. The nurse notes that the lochia is bright red and contains some small clots. Based on this data, the nurse should make which interpretation?

1-The client is hemorrhaging.
2-The client needs to increase oral fluids.
3-The client is experiencing normal lochia discharge.
4-The client's health care provider needs to be notified of the finding.

3-The client is experiencing normal lochia discharge.

Lochia, the uterine discharge present after birth, initially is bright red and may contain small clots. During the first 2 hours after birth, the amount of uterine discharge should be approximately that of a heavy menstrual period. After that time, the lochial flow should steadily decrease, and the color of the discharge should change to a pinkish red or reddish brown. Because this is a normal, expected occurrence, options 1, 2, and 4 are incorrect.

A nulliparous woman asks the nurse when she will begin to feel fetal movements. The nurse responds by telling the woman that the first recognition of fetal movement will occur at approximately how many weeks of gestation?

1-5 weeks
2-9 weeks
3-13 weeks
4-18 weeks

4-18 weeks

The first recognition of fetal movements, or feeling life, by the multiparous woman may occur as early as 14 to 16 weeks' gestation. The nulliparous woman may not notice these sensations until the 18 weeks' gestation or later. The first recognition of fetal movement is called quickening.

A nurse is performing a vaginal assessment of a pregnant woman who is in labor. The nurse notes that the umbilical cord is protruding from the vagina. The nurse would immediately take which action?

1-Administer oxygen to the woman.
2-Transport the woman to the delivery room.
3-Place an external fetal monitor on the woman.
4-Exert upward pressure against the presenting part using a gloved hand.

4-Exert upward pressure against the presenting part using a gloved hand.

If the umbilical cord is protruding from the vagina, no attempt should be made to replace it because doing so could traumatize it and further reduce blood flow. The nurse would place a gloved hand into the vagina to the cervix and exert upward pressure against the presenting part to relieve compression of the cord. The nurse also would wrap the cord loosely in a sterile towel saturated with warm, sterile normal saline solution. Oxygen, 8 to 10 L/min by face mask, would be administered to the mother to increase fetal oxygenation, and the woman would be prepared for immediate delivery. However, the immediate action is to relieve pressure on the cord. The woman should already have an external fetal monitor in place.

A nurse is assessing a woman in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which finding would the nurse expect to note if abruptio placentae is present?

1-Soft uterus
2-Abdominal pain
3-Nontender uterus
4-Painless vaginal bleeding

2-Abdominal pain

Classic signs and symptoms of abruptio placentae include vaginal bleeding, abdominal pain, and uterine tenderness and contractions. Mild to severe uterine hypertonicity is present. Pains is mild to severe and either localized or diffuse over one region of the uterus, with a board-like abdomen. Painless vaginal bleeding and a soft, nontender uterus in the second or third trimester of pregnancy are signs of placenta previa.

A nurse in the labor room is caring for a client who is in the first stage of labor. On assessing the fetal patterns, the nurse notes an early deceleration of the fetal heart rate (FHR) on the monitor strip. Based on this finding, which is the appropriate nursing action?

1-Contact the health care provider.
2-Place the mother in a Trendelenburg position.
3-Administer oxygen to the client by face mask.
4-Document the findings and continue to monitor fetal patterns

4-Document the findings and continue to monitor fetal patterns

Early deceleration of the FHR refers to a gradual decrease in the heart rate, followed by a return to baseline, in response to compression of the fetal head. It is a normal and benign finding. Because early decelerations are considered benign, interventions are not necessary. Therefore, options 1, 2, and 3 are unnecessary.

A woman in the third trimester of pregnancy with a diagnosis of mild preeclampsia is being monitored at home. The home care nurse teaches the woman about the signs that need to be reported to the health care provider. The nurse should tell the woman to call the health care provider if which occurs?

1-Urine tests negative for protein.
2-Fetal movements are more than four per hour.
3-Weight increases by more than 1 pound in a week.
4-The blood pressure reading is ranging between 122/80 and 132/88 mm Hg.

3-Weight increases by more than 1 pound in a week.

The nurse would instruct the client to report any increase in blood pressure, protein in the urine, weight gain greater than 1 pound per week, or edema. The client also is taught how to count fetal movements and is instructed that decreased fetal activity (three or fewer movements per hour) may indicate fetal compromise and should be reported.

A woman in the third trimester of pregnancy visits the clinic for a scheduled prenatal appointment. The woman tells the nurse that she frequently has leg cramps, primarily when she is reclining. Once thrombophlebitis has been ruled out, the nurse should tell the woman to implement which measure to alleviate the leg cramps?

1-Apply heat to the affected area.
2-Take acetaminophen (Tylenol) every 4 hours.
3-Self-administer calcium carbonate tablets three times daily.
4-Purchase a chewable antacid that contains calcium and take a tablet with each meal.

1-Apply heat to the affected area.

Leg cramps may be a result of compression of the nerves supplying the legs by the enlarging uterus, a reduced level of diffusible serum calcium, or an increase in serum phosphorus. In the pregnant woman who complains of leg cramps, the nurse would perform further assessments to ensure that the client is not experiencing thrombophlebitis. Once this has been ruled out, the nurse would instruct the woman to place heat on the affected area, dorsiflex the foot until the spasm relaxes, or stand and walk. The health care provider may prescribe oral supplementation with calcium carbonate tablets or calcium hydroxide gel with each meal to increase the calcium level and lower the phosphorus level, but the nurse would not prescribe these or any other medications.

A nurse is preparing a pregnant woman for a transvaginal ultrasound examination. The nurse should tell the woman that which will occur?

1-She will feel some pain during the procedure.
2-She will be placed in a supine left side-lying position.
3-She will feel some pressure when the vaginal probe is moved.
4-She will need to drink 2 quarts of water to attain a full bladder

3-She will feel some pressure when the vaginal probe is moved.

Transvaginal ultrasonography, in which a lubricated probe is inserted into the vagina, allows evaluation of the pelvic anatomy. A transvaginal ultrasound examination is well tolerated by most women because it alleviates the need for a full bladder to perform the test. The woman is placed in a lithotomy position or with her pelvis elevated by towels, cushions, or a folded blanket. The procedure is not physically painful, although the woman may feel pressure as the probe is moved.

A client with portal-systemic encephalopathy is receiving oral lactulose (Chronulac) daily. The nurse should check which item to determine the effectiveness of this medication?

1-Lung sounds
2-Blood pressure
3-Blood ammonia level
4-Serum potassium level

3-Blood ammonia level

Lactulose is a hyperosmotic laxative and ammonia detoxicant. It is used to prevent or treat portal-systemic encephalopathy, including hepatic precoma and coma. It also is used to treat constipation. The medication retains ammonia in the colon (decreases the blood ammonia concentration), producing an osmotic effect. It promotes increased peristalsis and bowel evacuation, expelling ammonia from the colon. This medication has no effect on lung sounds, the blood pressure, or the serum potassium level.

The nurse notes that a client is receiving lamivudine (Epivir). The nurse determines that this medication has been prescribed to treat which condition?

1-Pancreatitis
2-Pharyngitis
3-Tonic-clonic seizures
4-Human immunodeficiency virus (HIV)

4-Human immunodeficiency virus (HIV)

Lamivudine is a nucleoside reverse transcriptase inhibitor and antiviral medication. It slows HIV replication and reduces the progression of HIV infection. It also is used to treat chronic hepatitis B and provide prophylaxis in health care workers who are at risk of acquiring HIV infection after occupational exposure to the virus. This medication is not used to treat the conditions identified in options 1, 2, and 3.

A nurse notes that a client is taking lansoprazole (Prevacid). On assessment of the client, the nurse should ask which question to determine the effectiveness of this medication?

1-"Has your appetite increased?"
2-"Are you experiencing any heartburn?"
3-"Do you have any problems with vision?"
4-"Do you experience any leg pain when walking?"

2-"Are you experiencing any heartburn?"

Lansoprazole is a gastric acid pump inhibitor that is used to treat gastric and duodenal ulcers, erosive esophagitis, and hypersecretory conditions. It also is used to treat gastroesophageal reflux disease (GERD). It is not used to treat problems with appetite, visual problems, or leg pain.

A client who has been hospitalized with a paranoid disorder refuses to turn off the lights in the room at night and states, "My roommate will steal me blind." Which is the appropriate response by the nurse?

1-"Why do you believe this?"
2-"Tell me more about the details of your belief."
3-"I hear what you are saying, but I don't share your belief."
4-"If you want a pass for tomorrow evening's movie, you'd better turn that light off this minute."

3-"I hear what you are saying, but I don't share your belief."

Paranoid beliefs are coping mechanisms used by the client and therefore are not easily relinquished. It is important not to support the belief and not to ridicule, argue, or criticize it. Option 1 places the client in a defensive position by asking "why." Option 2 encourages the client to expound on the belief when discussion should instead be limited. Option 4 threatens the client.

A client who has just received a diagnosis of asthma says to the nurse, "This condition is just another nail in my coffin." Which response by the nurse is therapeutic?

1-"Do you think that having asthma will kill you?"
2-"You seem very distressed over learning you have asthma."
3-"I'm not going to work with you if you can't view this as a challenge rather than a 'nail in your coffin.'"
4-"Asthma is a very treatable condition. It is important to properly administer your medications. Let's practice with your inhalant."

2-"You seem very distressed over learning you have asthma."

Clients who have learned that they have a chronic illness may exhibit denial, anger, or sarcasm because of fear associated with the chronic illness. It is important for the nurse to convey an accepting attitude to enhance mutual respect and trust. Option 1 reflects and paraphrases the client's words but is somewhat sarcastic. Option 3 is punitive in its approach, threatens the client, and sarcastically quotes the client's words. Option 4 lectures the client and does not deal directly with expressed concerns.

An older client is seen in the clinic for a physical examination. Laboratory studies reveal that the hemoglobin and hematocrit levels are low, indicating the need for further diagnostic studies and a blood transfusion. The client is a Jehovah's Witness and refuses to have a blood transfusion. The nurse should take which most appropriate action?

1-Try to convince the client of the need for the transfusion.
2-Speak to the family regarding the need for a blood transfusion.
3-Support the client's decision not to receive a blood transfusion.
4-Discuss with the client the results of the hemoglobin and hematocrit levels compared with normal levels.

3-Support the client's decision not to receive a blood transfusion.

A client's cultural and ethnic background influences the response to health, illness, surgery, and death. Awareness of cultural differences enhances the nurse's knowledge of how a health care experience may be perceived by the client or family. In the Jehovah's Witness religion, the administration of blood and blood products is forbidden; therefore the nurse would support the client's decision. Trying to convince the client of the need for the blood transfusion is inappropriate and does not respect the client's cultural beliefs. Speaking to the family is a violation to the client's right to confidentiality; in addition, it does not respect the client's cultural beliefs. Discussing the results of laboratory values is an indirect way of trying to convince the client of the need for a blood transfusion, which again is inappropriate and does not respect the client's cultural beliefs.

A postpartum woman with mastitis in the right breast complains that the breast is too sore for her to breast-feed her infant. The nurse should tell the client to implement which measure?

1-Pump both breasts and discard the milk.
2-Bottle-feed the infant on a temporary basis.
3-Breast-feed from the left breast and gently pump the right breast.
4-Stop breast-feeding from both breasts until this condition resolves.

3-Breast-feed from the left breast and gently pump the right breast.

A postpartum woman with mastitis in the right breast complains that the breast is too sore for her to breast-feed her infant. The nurse should tell the client to implement which measure?

A nurse is monitoring an infant for signs of increased intracranial pressure (ICP). On assessment of the fontanelles, the nurse notes that the anterior fontanelle bulges when the infant is sleeping. Based on this finding, which is the priority nursing action?

1-Increase oral fluids.
2-Document the finding.
3-Notify the health care provider.
4-Place the infant supine in a side-lying position.

3-Notify the health care provider.

The anterior fontanelle is diamond shaped and is located on the top of the head. It should be soft and flat in a normal infant, and it normally closes by 12 to 18 months of age. A larger-than-normal fontanelle may be a sign of increased ICP within the skull. Although the anterior fontanelle may bulge slightly when the infant cries, bulging at rest may indicate increased ICP. Options 1 and 4 are inaccurate interventions and will not be helpful. Although the nurse would document the finding, the priority action would be to report the finding to the health care provider.

The nurse is caring for a client who is receiving oxytocin (Pitocin) for induction of labor and notes a nonreassuring fetal heart rate (FHR) pattern on the fetal monitor. On the basis of this finding, the nurse should take which action first?

1-Stop the oxytocin infusion.
2-Check the client's blood pressure.
3-Check the client for bladder distention.
4-Place the client in a side-lying position

1-Stop the oxytocin infusion.

Oxytocin stimulates uterine contractions and is used to induce labor. If uterine hypertonicity or a nonreassuring FHR pattern occurs, the nurse needs to intervene to reduce uterine activity and increase fetal oxygenation. The oxytocin infusion is stopped, the client is placed in a side-lying position, and oxygen by face mask at 8 to 10 L/min is administered. The health care provider is notified. The nurse would monitor the client's blood pressure and intake and output; however, the nurse would first stop the infusion.

A nurse performs an assessment of a pregnant woman who is receiving intravenous magnesium sulfate for management of preeclampsia and notes that the woman's deep tendon reflexes are absent. On the basis of this finding, the nurse should make which interpretation?

1-The infusion rate needs to be increased.
2-The magnesium sulfate is effective.
3-The woman is experiencing cerebral edema.
4-Magnesium toxicity can occur as a result of magnesium sulfate therapy.

Signs of magnesium sulfate toxicity relate to the central nervous system depressant effects of the medication and include respiratory depression, loss of deep tendon reflexes, sudden decrease in fetal heart rate or maternal heart rate or both, and sudden drop in blood pressure. An absence of reflexes indicates magnesium excess. The infusion rate therefore would not be increased. Hyperreflexia indicates increased cerebral edema. The woman is experiencing magnesium excess.

Methylergonovine (Methergine) is prescribed for a woman with postpartum hemorrhage caused by uterine atony. Before administering the medication, the nurse should check which most important client parameter?

1-Lochial flow
2-Urine output
3-Temperature
4-Blood pressure

4-Blood pressure

Methylergonovine is an ergot alkaloid used for postpartum hemorrhage. It stimulates contraction of the uterus and causes arterial vasoconstriction. Ergot alkaloids are avoided in women with significant cardiovascular disease, peripheral disease, hypertension, eclampsia, or preeclampsia. Such conditions are worsened by the vasoconstrictive effects of the ergot alkaloids. The nurse would assess the woman's blood pressure before administering the medication and would follow agency protocols regarding withholding of the medication. Options 1, 2, and 3 are items that are assessed in the postpartum period, but they are unrelated to the use of this medication.

A nurse is monitoring a newborn infant who has been circumcised. The nurse notes that the infant has a temperature of 100.6° F and that the dressing at the circumcised area is saturated with a foul-smelling drainage. Which is the priority nursing action?

1-Reinforce the dressing.
2-Document the findings.
3-Contact the health care provider.
4-Swab the drainage and send the sample to the laboratory for culture.

3-Contact the health care provider.

Complications after circumcision include bleeding, failure to urinate, displacement of the Plastibell, and infection (indicated by a fever and a purulent or foul-smelling drainage). If signs of infection occur, the health care provider is notified. The nurse would change, not reinforce, the dressing; reinforcing the dressing leaves the foul smelling drainage in contact with the surgical site. The nurse would document the findings, but this is not the priority item. The health care provider will prescribe a culture if it is necessary; it is not within the realm of nursing responsibilities to prescribe a diagnostic test.

The nurse receives a telephone call from the admissions office and is told that a child with acute bacterial meningitis will be admitted to the pediatric unit. The nurse prepares for the child's arrival and plans to implement which type of precautions?

1-Enteric
2-Contact
3-Droplet
4-Neutropenic

3-Droplet

A major priority in nursing care for a child with suspected meningitis is to administer the appropriate antibiotic as soon as it is prescribed. The child will be placed in a private room, with droplet transmission precautions, for at least 24 hours after antibiotics are given. Enteric, contact, and neutropenic precautions are not associated with the mode of transmission of meningitis. Enteric precautions are instituted when the mode of transmission is through the gastrointestinal tract. Contact precautions are instituted when contact with infectious items or materials is likely. Neutropenic precautions are instituted when the client has a low neutrophil count.

The clinic nurse reads the results of a tuberculin skin test performed on a 5-year-old child who is at low risk for contracting tuberculosis. The results indicate an area of induration measuring 10 mm. How would the nurse interpret these results?

1-Positive
2-Negative
3-Inconclusive
4-Definitive and requiring a repeat test

2-Negative

Induration measuring 15 mm or greater is considered a positive result in a child 4 years of age or older who has no associated risk factors. Options 1, 3, and 4 are incorrect interpretations.

The nurse is providing home care instructions to the mother of a child who has bacterial conjunctivitis. The nurse should provide the mother with which information?

1-The child may attend school if antibiotics have been started.
2-Any unused eye medication should be saved in case a sibling gets the eye infection.
3-The child's towels and washcloths should not be used by other members of the household.
4-Any crusted material should be wiped from the eye with a cotton ball soaked in warm water, starting at the outer aspect of the eye and moving toward the inner aspect.

3-The child's towels and washcloths should not be used by other members of the household.

Bacterial conjunctivitis is highly contagious, and infection control measures should be taught. These include good handwashing and not sharing towels or washcloths with others. The child should be kept home from school until 24 hours after antibiotics are started. Bottles of eye medication should never be shared with others. Crusted material may be wiped from the eye with a cotton ball soaked in warm water, starting at the inner aspect of the eye and moving toward the outer aspect.

The mother of 6-year-old twins says to the nurse, "My mother-in-law doesn't think our children should come to the funeral service for their grandfather. What do you advise?" The nurse most appropriately responds by making which statement?

1-"What do you and your husband believe is the right thing for your children?"
2-"By all means have them attend. Not to do so would promote postmortem grief."
3-"It's a difficult decision, but given their young age, perhaps omitting the wake and just including the funeral would be best."
4-"I agree with your mother-in-law. Your mother-in-law is upset enough as it is. Tell your children that their grandfather is in heaven."

1-"What do you and your husband believe is the right thing for your children?"

The most therapeutic response is the one that encourages open expression of feelings and empowers the grieving relative. Values, beliefs, and practices differ depending on the client's ethnic and spiritual backgrounds, and the nurse should not push a decision based on the nurse's own belief system. Options 2, 3, and 4 are nontherapeutic. Option 2 provides incorrect information related to postmortem grieving. Options 3 and 4 offer the nurse's opinion and impose the nurse's own beliefs.

A 63-year-old woman whose husband died 2 months ago says to the visiting nurse, "My daughter came over yesterday to help me move my husband's things out of our bedroom, and I was so angry with her for moving his slippers from where he always kept them under his side of our bed. She doesn't know how much I'm hurting." Which statement by the nurse would be therapeutic?

1-"I know just how you feel because I lost my husband last summer."
2-"It's OK to grieve and be angry with your daughter and anyone else for a time."
3-"You need to focus on the many good years you both enjoyed together and move on."
4-"Although it's a troubling time for you, try to focus on your children and grandchildren."

2-"It's OK to grieve and be angry with your daughter and anyone else for a time."

The therapeutic statement is the one that gives the client permission to grieve and acknowledges that anger is part of loss and that it may be aimed at the people who are trying most to help and are closest. Options 1, 3, and 4 are all nontherapeutic. They do not encourage the client to express feelings.