Correct Answer: C

Rationale: The correct answer is C: Sun-downing syndrome. Sun-downing syndrome is a phenomenon commonly seen in individuals with dementia, where they exhibit increased confusion and agitation in the late afternoon or evening. This pattern of behavior is believed to be linked to disruptions in the circadian rhythm and can be triggered by factors such as fatigue, low lighting, or increased shadows during the evening.

Choices A and B, anxiety and depression, may be comorbid conditions in individuals with dementia but are not the primary explanation for the symptoms described. While medication side effects (
Choice
D) should always be considered in a client with dementia, given the time-specific nature of the symptoms, sun-downing syndrome is the most likely explanation in this case.

Correct Answer: D

Rationale: The client's dangerous and disruptive behaviors, along with auditory hallucinations of self-harm, suggest a need for involuntary commitment for his safety and that of others. Involuntary commitment may be warranted based on the client's poor hygiene and self-neglect, as it indicates an inability to care for himself, which can pose a risk to his well-being.

Correct Answer: A

Rationale: Acute confusion is the priority problem as it directly affects the client's ability to process information and make safe decisions. In this scenario, the client's disorientation, disorganization, and confusion indicate an immediate cognitive issue that requires attention to ensure her safety and stability.

Choices B, C, and D are not the priority problems in this case. Ineffective community coping, disturbed sensory perception, and self-care deficit, while important, are secondary to the client's acute confusion, which poses an immediate risk to her well-being.

Correct Answer: B

Rationale: The nurse should first ask if the client is ever alone when she hears the voices. This question helps differentiate between potential auditory hallucinations and other causes like hearing loss.
Choice A is not the best first question as it assumes the client is experiencing hallucinations without exploring other possibilities.
Choice C is irrelevant to the immediate concern of hearing voices.
Choice D pertains to visual hallucinations which are not described in the client's complaint of hearing voices.

Correct Answer: A

Rationale: The most important nursing diagnosis for discharge planning in this scenario is 'Ineffective denial related to situational anxiety.' The client's insistence on returning to his apartment despite being informed otherwise indicates a form of denial, possibly due to anxiety about the situational change. Focused discharge planning should address this denial and the underlying anxiety to ensure a smooth transition.

Choices B, C, and D are not as relevant in this context as the primary issue lies in the client's denial and anxiety regarding the change in living arrangements, rather than coping, social interactions, or self-care deficits.