Correct Answer: A

Rationale: During a client assessment, noting and documenting nonverbal messages is important as it captures the full context of the client's communication. Nonverbal cues can often reveal underlying emotions or issues that may not be expressed verbally. Asking the client's husband to interpret the discrepancy (
Choice
B) may not be appropriate as it could potentially breach the client's privacy and trust. Ignoring nonverbal behavior (
Choice
C) can result in missing important cues that could impact the care provided. Integrating verbal and nonverbal messages (
Choice
D) is beneficial, but the initial step should be to pay close attention and document the nonverbal messages to fully understand the client's communication.

Correct Answer: D

Rationale: In this scenario, the client is experiencing hallucinations and symptoms of alcohol withdrawal. Lorazepam (Ativan) is the appropriate choice as it helps manage withdrawal symptoms, including hallucinations and elevated blood pressure in alcohol-dependent clients. Haloperidol (Haldol) (
Choice
A) is an antipsychotic but is not the first-line treatment for alcohol withdrawal symptoms. Thiamine (Vitamin B1) (
Choice
B) is essential in alcohol withdrawal treatment for preventing Wernicke's encephalopathy, but in this case, addressing the acute withdrawal symptoms is the priority. Diphenhydramine (Benadryl) (
Choice
C) is an antihistamine that may help with itching or mild anxiety but is not the preferred choice for managing alcohol withdrawal symptoms like hallucinations and elevated blood pressure.

Correct Answer: A

Rationale: Alcohol use disorder is commonly associated with schizophrenia, leading to a dual diagnosis. Assessing for alcohol use disorder is crucial in managing the patient's overall well-being and treatment plan. Major depressive disorder can co-occur with schizophrenia but is not the most commonly associated condition. Stomach cancer is not typically associated with schizophrenia. Polydipsia, excessive thirst, can be a symptom in some individuals with schizophrenia due to medication side effects, but it is not an associated condition that requires frequent assessment compared to alcohol use disorder.

Correct Answer: D

Rationale: The best intervention for a male client with schizophrenia displaying echolalia, which is disruptive to others, is for the nurse to escort the client to his room. Echolalia, the constant repetition of others' words, can be disruptive in a communal setting. By guiding the client to a private space like his room, the nurse helps manage the behavior without isolating or medicating the client unnecessarily. Avoiding acknowledging the behavior (
Choice
A) does not address the issue, isolating the client (
Choice
B) may exacerbate feelings of exclusion, and administering a PRN sedative (
Choice
C) should be reserved for situations where there is imminent risk or severe agitation, not for managing echolalia.

Correct Answer: D

Rationale: A mental status examination is the most important assessment for the nurse to obtain in this scenario. It provides a comprehensive view of the client's current cognitive functioning, including their level of alertness, orientation, memory, attention, and thought process. Understanding the client's mental status is crucial for developing an appropriate treatment plan. The other options, such as motivation for treatment, history of substance use, and medication compliance, are important aspects to consider but may not directly address the client's current cognitive state and immediate treatment needs as effectively as a mental status examination.