Milestone Exam 2- Version
A
. Display name
Node number
NSG221.12.01. Schizophrenia care Be sincere and honest when communicating with
05 client. Avoid vague or evasive remarks.
Delusional clients are extremely sensitive about others and can
recognize insincerity. Evasive comments or hesitation reinforces
mistrust or delusions. Be consistent in setting expectations,
enforcing rules and so forth.
Clear consistent limits provide a secure structure for the
client. Do not make promises that you cannot keep.
Broken promises reinforce the client’s mistrust of others.
Encourage client to talk with you, but do not pry for information.
Probing increases the client’s suspicion and interferes with the
therapeutic relationship. Explain procedures and try to be sure the
client understands the procedures before carrying them out. When
client has full knowledge of procedures, he or she is less likely to feel
tricked by staff.
Give positive feedback for the client’s successes.
Positive feedback for genuine success enhances the client’s sense of
well-being and helps make non delusional reality a more positive
situation for the client.
Clients may also fail to recognize sensations such as hunger or thirst,
and food or fluid intake may be inadequate. This can result in
malnourishment and constipation.
NSG221.04.0 Grief therapeutic response
2. 04
BOX 10.1Dimensions (Responses) and Symptoms of the Grieving Client
Disruption of assumptions and beliefs
Questioning and trying to make sense of the loss
Cognitive responses
Attempting to keep the lost one present
Believing in an afterlife and as though the lost one is a
guide
Emotional Anger, sadness,
responses
anxiety Resentment
Guilt
Feeling numb
Vacillating
1
,Milestone Exam 2- Version
A
e
m
o
t
i
o
n
s
Profound sorrow,
loneliness
2
,Milestone Exam 2- Version
A
Intense desire to restore bond with lost one or
object
n
Depression, apathy, despair during phase of
disorganizatio
Sense of independence and confidence as phase
of reorganization evolves
Disillusioned and angry with God
Spiritual responses Anguish of abandonment or perceived
abandonment Hopelessness, meaninglessness
Functioning “automatically”
Tearful sobbing, uncontrollable
crying Great restlessness, searching
behaviors Irritability and hostility
Behavioral Seeking and avoiding places and activities shared on
responses
with lost Keeping valuables of lost one while em
wanting to discard the Possibly abusing drugs or
alcohol
Possible suicidal or homicidal gestures or attempts
Seeking activity and personal reflection during
phase of reorganization
Headaches, insomnia
Impaired appetite, weight
Physiologic loss Lack of energy
responses
Palpitations, indigestion
Changes in immune and endocrine systems
3
, Milestone Exam 2- Version
A
It is essential to remember that the grieving response is individual. In
any of the theories, steps, or tasks, individuals may move back and
forth, may spend a long time in one particular phase, or pass through a
phase so quickly it is not recognized. There is no one right way to
grieve. It is a dynamic process, not an orderly progression through
easily identifiable stages.
While observing client responses in the dimensions of grieving,
the nurse explores three critical components in assessment:
• Adequate perception regarding the loss
• Adequate support while grieving for the loss
• Adequate coping behaviors during the process
Perception of the Loss
Assessment begins with exploration of the client’s perception of the
loss. What does the loss mean to the client? For the woman who has
spontaneously lost her first unborn child and the woman who has
elected to abort a pregnancy, this question could have similar or
different answers. Nevertheless, the question is valuable for beginning
to facilitate the grief process.
Other questions that assess perception and encourage the client’s
movement through the grief process include the following:
• What does the client think and feel about the loss?
• How is the loss going to affect the client’s life?
• What information does the nurse need to clarify or share with the
client?
Assessing the client’s “need to know” in plain and simple language
invites the client to verbalize perceptions that may need clarification.
This is especially true for the person who is anticipating a loss, such
as one facing a life-ending illness or the loss of a body part. The nurse
uses open-ended questions and helps clarify any misperceptions.
Support
Purposeful assessment of support systems provides the grieving client
with an awareness of those who can meet his or her emotional and
spiritual needs for security and love. The nurse can help the client
identify his or her support systems and reach out and accept what
they can offer.
Nurse: “Who in your life should or would really want to know
4
A
. Display name
Node number
NSG221.12.01. Schizophrenia care Be sincere and honest when communicating with
05 client. Avoid vague or evasive remarks.
Delusional clients are extremely sensitive about others and can
recognize insincerity. Evasive comments or hesitation reinforces
mistrust or delusions. Be consistent in setting expectations,
enforcing rules and so forth.
Clear consistent limits provide a secure structure for the
client. Do not make promises that you cannot keep.
Broken promises reinforce the client’s mistrust of others.
Encourage client to talk with you, but do not pry for information.
Probing increases the client’s suspicion and interferes with the
therapeutic relationship. Explain procedures and try to be sure the
client understands the procedures before carrying them out. When
client has full knowledge of procedures, he or she is less likely to feel
tricked by staff.
Give positive feedback for the client’s successes.
Positive feedback for genuine success enhances the client’s sense of
well-being and helps make non delusional reality a more positive
situation for the client.
Clients may also fail to recognize sensations such as hunger or thirst,
and food or fluid intake may be inadequate. This can result in
malnourishment and constipation.
NSG221.04.0 Grief therapeutic response
2. 04
BOX 10.1Dimensions (Responses) and Symptoms of the Grieving Client
Disruption of assumptions and beliefs
Questioning and trying to make sense of the loss
Cognitive responses
Attempting to keep the lost one present
Believing in an afterlife and as though the lost one is a
guide
Emotional Anger, sadness,
responses
anxiety Resentment
Guilt
Feeling numb
Vacillating
1
,Milestone Exam 2- Version
A
e
m
o
t
i
o
n
s
Profound sorrow,
loneliness
2
,Milestone Exam 2- Version
A
Intense desire to restore bond with lost one or
object
n
Depression, apathy, despair during phase of
disorganizatio
Sense of independence and confidence as phase
of reorganization evolves
Disillusioned and angry with God
Spiritual responses Anguish of abandonment or perceived
abandonment Hopelessness, meaninglessness
Functioning “automatically”
Tearful sobbing, uncontrollable
crying Great restlessness, searching
behaviors Irritability and hostility
Behavioral Seeking and avoiding places and activities shared on
responses
with lost Keeping valuables of lost one while em
wanting to discard the Possibly abusing drugs or
alcohol
Possible suicidal or homicidal gestures or attempts
Seeking activity and personal reflection during
phase of reorganization
Headaches, insomnia
Impaired appetite, weight
Physiologic loss Lack of energy
responses
Palpitations, indigestion
Changes in immune and endocrine systems
3
, Milestone Exam 2- Version
A
It is essential to remember that the grieving response is individual. In
any of the theories, steps, or tasks, individuals may move back and
forth, may spend a long time in one particular phase, or pass through a
phase so quickly it is not recognized. There is no one right way to
grieve. It is a dynamic process, not an orderly progression through
easily identifiable stages.
While observing client responses in the dimensions of grieving,
the nurse explores three critical components in assessment:
• Adequate perception regarding the loss
• Adequate support while grieving for the loss
• Adequate coping behaviors during the process
Perception of the Loss
Assessment begins with exploration of the client’s perception of the
loss. What does the loss mean to the client? For the woman who has
spontaneously lost her first unborn child and the woman who has
elected to abort a pregnancy, this question could have similar or
different answers. Nevertheless, the question is valuable for beginning
to facilitate the grief process.
Other questions that assess perception and encourage the client’s
movement through the grief process include the following:
• What does the client think and feel about the loss?
• How is the loss going to affect the client’s life?
• What information does the nurse need to clarify or share with the
client?
Assessing the client’s “need to know” in plain and simple language
invites the client to verbalize perceptions that may need clarification.
This is especially true for the person who is anticipating a loss, such
as one facing a life-ending illness or the loss of a body part. The nurse
uses open-ended questions and helps clarify any misperceptions.
Support
Purposeful assessment of support systems provides the grieving client
with an awareness of those who can meet his or her emotional and
spiritual needs for security and love. The nurse can help the client
identify his or her support systems and reach out and accept what
they can offer.
Nurse: “Who in your life should or would really want to know
4
