Correct Answer: B

Rationale: Teaching the client to turn his head from side to side for visual scanning is essential in addressing unilateral neglect syndrome caused by a cerebrovascular accident. This action helps improve visual awareness and assists the client in overcoming the neglect of one side of the body. Providing additional light for sensory stimulation (
Choice
A) may not directly address the issue of unilateral neglect. Placing a clock and calendar in the room (
Choice
C) may be helpful for orientation but does not specifically target unilateral neglect. Using hand and arm gestures for communication (
Choice
D) may aid in communication but does not directly address the visual scanning deficits associated with unilateral neglect syndrome.

Correct Answer: C

Rationale: The nurse's signature on the consent form signifies that the client is competent to sign the consent without impairment of judgment. This legal implication ensures that the client possesses the necessary capacity to make decisions about their healthcare.
Choice A is incorrect because the nurse's signature does not imply the client's voluntary permission for the procedure.
Choice B is incorrect as it pertains to the surgeon's responsibility, not the nurse's.
Choice D is incorrect as the nurse's signature does not confirm the client's understanding of the risks and benefits associated with the procedure.

Correct Answer: C

Rationale: The client's grimacing and guarding suggest pain; assessing the pain scale is crucial for addressing the discomfort. Pain management is a priority to ensure the client's well-being and comfort. Checking the apical heart rate, IV site and fluids, or temperature can be important but addressing the client's pain takes precedence in this scenario. The elevated pulse rate and respiratory rate could be indicative of pain, making the pain scale assessment essential to guide appropriate interventions.

Correct Answer: A

Rationale: In this scenario, the most appropriate interdisciplinary team member for the nurse to consult is a hospice nurse. Hospice nurses specialize in managing pain and symptom control, which aligns with the client's needs for managing severe chronic pain. While pain specialists (choice
B) focus on pain management, in this case, the client specifically requested hospice care for pain management. Consulting a psychologist (choice
C) may be beneficial for addressing psychological aspects, but the client's immediate need is pain management. Forming an interdisciplinary team (choice
D) is not as specific as consulting a hospice nurse, who has the specialized skills required to address the client's pain effectively.

Correct Answer: D

Rationale: The correct answer is D: Impaired environmental interpretation related to paranoid delusions. The client's belief about cameras watching and recording him is a manifestation of paranoid delusions, indicating a misinterpretation of the environment.
Choice A is incorrect because thought broadcasting is not directly related to the client's belief about surveillance equipment.
Choice B is incorrect as self-esteem disturbance is not the primary issue presented.
Choice C is also incorrect as the client is not experiencing auditory hallucinations but rather paranoid delusions about surveillance.