Correct Answer: B

Rationale: The correct answer is B because it highlights the importance of checking for congruence between verbal and nonverbal communication to validate responses. This demonstrates an understanding that nonverbal cues can provide additional insights into a patient's true feelings or thoughts.
Choice A is incorrect as it simply states a general observation without emphasizing the significance of nonverbal cues.
Choice C is incorrect because assuming a patient's emotions based solely on body posture is not accurate or reliable.
Choice D is incorrect as it undervalues the importance of nonverbal communication in understanding the complete message being conveyed.

Correct Answer: C

Rationale: The correct answer is C: "We've installed locks on all the outside doors." This statement shows an understanding of the need to prevent the patient with dementia from wandering off and getting lost or injured. Installing locks on outside doors helps to ensure the patient's safety by limiting their ability to leave the house unsupervised. This measure is crucial in providing a secure environment for someone with dementia.


Explanation:
A: The statement about the local police knowing the patient has wandered off before does not address the immediate need to prevent wandering and ensure safety.
B: Keeping the noise level low in the house may be helpful for a patient with dementia, but it does not directly address the safety concern of wandering.
D: Attaching the telephone number to the patient's shirt pocket is a good safety measure, but it does not address the primary concern of preventing the patient from wandering off.

Correct Answer: C

Rationale: The correct answer is C. Administer prescribed medication morphine for pain control. In this scenario with a 'DNR-CCO' order, the focus is on comfort care rather than resuscitation. Administering morphine for pain control aligns with the patient's wishes and provides comfort during a potentially distressing event. Calling for the code team (
A) and initiating CPR (
D) would go against the DNR order. Notifying the attending physician and family (
B) is important but not the immediate nursing action needed during a cardiac arrest in this case.

Correct Answer: D

Rationale: The correct answer is D: transition of care. Transition of care refers to clients moving between treatment settings, ensuring continuity and coordination of care. Rehospitalization (
A) specifically refers to clients being admitted back to the hospital. Adverse event (
B) refers to harm resulting from medical care. Readmission (
C) is similar to rehospitalization, specifically indicating clients being admitted back to a hospital after a previous discharge. Transition of care (
D) is the most appropriate term as it encompasses the movement of clients between various healthcare settings beyond just hospitals.

Correct Answer: B

Rationale: The correct answer is B because assessing alcohol and tobacco use in a pregnant client with depression is crucial for providing comprehensive care. First, substance use can exacerbate mental health symptoms and impact treatment effectiveness. Second, substance use during pregnancy can harm both the mother and the unborn child, leading to adverse health outcomes. Third, this information is vital for developing a holistic care plan that considers both the mental health needs of the client and the safety of the unborn child.



Choices A, C, and D are incorrect because:
A: Failing to assess alcohol and tobacco use neglects essential information that can impact the client's well-being and treatment.
C: Substance use during pregnancy can have significant long-term effects on the unborn child's health and development.
D: Assessing alcohol and tobacco use is not optional, as it directly influences the client's mental health and the well-being of the unborn child.