Author Question: The nurse is caring for a client admitted for severe weight loss and depression. The client recently ... (Read 101 times)

azncindy619 · **on:** Jun 25, 2018

The nurse is caring for a client admitted for severe weight loss and depression. The client recently experienced the loss of three close family members and has withdrawn from all social activities.

In developing the plan of care, the nurse would correctly choose which nursing diagnosis?
1. Powerlessness.
2. Anxiety.
3. Complicated grieving.
4. Spiritual distress.

Question 2

The nurse is reviewing the plan of care for a client who was admitted for suicidal tendencies. The nurse documents that the client is no longer experiencing thoughts of hurting self. Which step of the nursing process is the nurse using?

1. Implementation.
2. Evaluation.
3. Planning.
4. Assessment.

mcarey591 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Correct Answer: 3

Clients experiencing tremendous loss often develop depression as part of their reaction to grief. However, this depression should also be seen with other stages of the grieving process such as denial, anger, bargaining, and acceptance. Clients remaining in one stage of the grieving process may not be progressing toward acceptance. There are not enough data to support the remaining nursing diagnoses. Powerlessness refers to feelings of a loss of control with the situation. Anxiety infers feelings of apprehension. Spiritual distress infers the client would be at odds with her feelings.

Answer to Question 2

Correct Answer: 2

Evaluation is the process whereby the progress toward achieving the goals is reviewed and documented. Implementation is the process of performing certain interventions designed to move the client toward achievement of the goal. During the planning phase of the nursing process, nursing diagnoses are formulated after data have been assessed, and then goal setting takes place. Assessment is the process by which data are collected.