Milestone Exam 2- Version A

Node number Display name NSG221.12.01. 05 Schizophrenia care Be sincere and honest when communicating with 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. NSG221.04.02. 04 Grief therapeutic response BOX 10.1Dimensions (Responses) and Symptoms of the Grieving Client Cognitive responses Disruption of assumptions and beliefs Questioning and trying to make sense of the loss Attempting to keep the lost one present Believing in an afterlife and as though the lost one is a guide Emotional responses Anger, sadness, anxiety Resentment Guilt Feeling numb Vacillating emotions Profound sorrow, loneliness 1 Milestone Exam 2- Version A Intense desire to restore bond with lost one or object Depression, apathy, despair during phase of disorganization Sense of independence and confidence as phase of reorganization evolves Spiritual responses Disillusioned and angry with God Anguish of abandonment or perceived abandonment Hopelessness, meaninglessness Behavioral responses Functioning “automatically” Tearful sobbing, uncontrollable crying Great restlessness, searching behaviors Irritability and hostility Seeking and avoiding places and activities shared with lost one Keeping valuables of lost one while wanting to discard them Possibly abusing drugs or alcohol Possible suicidal or homicidal gestures or attempts Seeking activity and personal reflection during phase of reorganization Physiologic responses Headaches, insomnia Impaired appetite, weight loss Lack of energy Palpitations, indigestion Changes in immune and endocrine systems 2 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