Author Question: An adult tells the nurse, I can't take it anymore Last year my husband had an affair and now we ... (Read 44 times)

Metfan725 · **on:** Jul 19, 2018

An adult tells the nurse, I can't take it anymore Last year my husband had an affair and now we don't communicate. Three months ago, I found a lump in my breast. Yesterday my daughter told me she's quitting college and moving in with her boyfriend.

What is the priority nursing diagnosis?

a. Fear, related to impending surgery
b. Deficient knowledge, related to breast lesion
c. Ineffective coping, related to perceived loss of daughter
d. Impaired verbal communication, related to spousal estrangement

Question 2

A woman says, I can't take it anymore Last year my husband had an affair and now we don't communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she's quitting college.

If this person's immediate family is unable to provide sufficient situational support, the nurse should:

a. suggest hospitalization for a short period.
b. ask what other relatives or friends are available for support.
c. tell the patient, You must be strong. Don't let this crisis overwhelm you.
d. foster insight by relating the present situation to earlier situations involving loss.

Jane · **Reply #1 on:** Jul 19, 2018

Answer to Question 1

ANS: C
This nursing diagnosis is the priority because it reflects the precipitating event associated with the patient's crisis. Data are not present to make the other diagnoses of Deficient knowledge, Fear, or Impaired verbal communication.

Answer to Question 2

ANS: B
The assessment of situational supports should continue. Although the patient's nuclear family may not be supportive, other situational supports may be available. If they are adequate, admission to an inpatient unit will be unnecessary. Psychotherapy is not appropriate for crisis intervention. Advice is usually nontherapeutic.