Correct Answer: B

Rationale: Exploring the client's readiness to discuss the situation is the correct first step. It allows the nurse to assess the client's emotional state, willingness to seek help, and readiness to address the abusive relationship. This approach helps build trust and rapport with the client, paving the way for further interventions. Discussing treatment options for abusive partners (
Choice
A) may be premature and not well-received if the client is not ready to address the situation. Determining the frequency and type of abuse (
Choice
C) is important but not the immediate priority compared to assessing the client's readiness to talk. Reporting the finding to the police (
Choice
D) should be done if there is an immediate threat to the client's safety, but exploring the client's readiness to discuss the situation should be the initial step to provide support and intervention.

Correct Answer: C

Rationale: The correct action for the nurse to take in this situation is to assess the content of the hallucinations by asking the client what he is hearing (
C). Further assessment is needed to understand the nature of the client's delusions and hallucinations.
Choice A is incorrect as it focuses on reassuring the client about his fear, which is not addressing the underlying issue of the delusional statement.
Choice B is incorrect as it argues with the client's delusion and offers false reassurance, which is not therapeutic.
Choice D is incorrect as ignoring the behavior and making no response disregards the client's needs for assessment and support.

Correct Answer: D

Rationale: In this scenario, the best response for the nurse is to offer presence and a safe environment without validating the delusion or arguing with the client. By inviting the client to the room and offering to sit with her, the nurse is providing support and reassurance.
Choice A is incorrect because directly denying the client's belief may escalate the situation.
Choice B is inappropriate as it dismisses the client's concerns without addressing the underlying issue.
Choice C acknowledges the client's feelings but does not provide immediate support or safety, unlike
Choice D which offers both.

Correct Answer: C

Rationale: In critical care environments, stressors can lead to isolation and confusion. Providing the client with scheduled rest periods (
C) can help alleviate these symptoms. Moving all machines away (
A) is impractical as they are often essential. Explaining the condition (
B) may not be effective during acute confusion. Extending visitation times (
D) can be overwhelming for the client in the ICU.

Correct Answer: C

Rationale: Reducing the noise level in the room by turning off the television and radio is the best choice among the options provided. This setting helps create a calm and focused environment, which facilitates better communication and assessment during the interview. Dimming the lights might not be suitable for all clients and could potentially hinder communication. Sitting too close or placing a table between the client and the RN may affect the client's comfort level and openness during the interview.