A home health nurse is conducting a visit for a 72-year-old client whose adult child died unexpectedly in a motor vehicle collision two days ago. Upon the nurse's arrival, the client is pacing rapidly, clutching their chest, and crying, 'I cannot breathe, my heart is breaking, make it stop!' The client's 14-year-old grandchild is sitting silently in the corner of the room. Which of the following nursing actions are appropriate? Select all that apply.
- Remain with the client and immediately assess their vital signs and respiratory status.Answer
- Speak to the client using a calm tone and short, simple sentences.Answer
- Validate the client's emotional pain by stating, 'You are experiencing an unimaginable loss right now.'Answer
- DAdvise the 14-year-old grandchild to stay strong and suppress their emotions to avoid upsetting the client further.
- EOffer comfort by telling the client, 'Everything happens for a reason, and time will heal this pain.'
- FPostpone the physical assessment of the client's chest pain to prioritize completing the required bereavement intake paperwork.
Answer
The correct actions are to remain with the client to assess vital signs immediately, speak in a calm tone using short sentences, and validate the client's emotional pain.
The correct interventions prioritize client safety while providing appropriate psychosocial support. A client presenting with chest pain and shortness of breath must immediately be assessed physiologically to rule out a medical emergency, even in the context of acute grief. Because severe anxiety impairs cognitive processing, the nurse should use short, simple sentences. Validating the client's profound loss demonstrates empathy and builds a therapeutic relationship.
Step-by-Step Solution
Key Concept
In acute grief presenting with physical symptoms, the nurse must first prioritize physiological safety (ABCs) and then use crisis and therapeutic communication techniques, while respecting the developmental grieving needs of all family members.