A 52-year-old male client who has a history of alcohol dependence is admitted to a detoxification unit. He has tremors, he is anxious, his pulse has risen from 98 to 110 beats/min, his blood pressure has risen from 140/88 to 152/100 mm Hg, and his temperature is six tenths of a degree above normal. He is slightly diaphoretic. Which nursing diagnosis would be the priority?

Correct Answer: B

Rationale: The correct answer is B: Risk for Injury. The priority nursing diagnosis in this scenario is based on the client's physical symptoms and potential harm to himself. The client's tremors, anxiety, elevated pulse and blood pressure, increased temperature, and diaphoresis indicate symptoms of alcohol withdrawal, which can lead to seizures or delirium tremens. The client is at risk for injury due to these physiological manifestations. Disturbed Thought Processes (A) may be present, but addressing the risk for injury takes precedence. Ineffective Coping (C) and Ineffective Denial (D) may be relevant, but they are not as urgent as ensuring the client's safety from potential harm during alcohol withdrawal.

Correct Answer: C

Rationale: Step 1: Homeless individuals often face extreme stressors like lack of shelter, food, and safety. Step 2: Coping mechanisms are crucial for survival in such challenging conditions. Step 3: Resiliency refers to the ability to adapt and thrive despite adversity. Step 4: Therefore, the correct choice is C, as coping with extreme stressors demonstrates resiliency. Summary: A is incorrect because strong community supports may not always be available. B is incorrect since homeless individuals may not have access to family resources. D is incorrect as local governmental intervention may not directly impact individual resiliency.

Correct Answer: B

Rationale: The correct answer is B: Adequate reimbursement. This is the correct answer because reimbursement issues do not typically act as a barrier to pain management. It is important for healthcare professionals to provide pain management regardless of reimbursement concerns. In contrast, fear of tolerance (A), concern for being a good client (C), and reluctance to report pain (D) are common barriers to pain management that can impact patient care and outcomes. Patients may fear developing tolerance to pain medications, may be hesitant to report pain due to concerns about being seen as a difficult patient, or may simply be reluctant to report pain altogether. Addressing these barriers is crucial for effective pain management.

Correct Answer: B

Rationale: The correct answer is B because applying heat to a sprained ankle within the first 48 hours can increase swelling and inflammation. This can delay the healing process and worsen the injury. The other choices are appropriate for caring for a sprained ankle. A: Elevating the extremity helps reduce swelling. C: Compression dressing helps support the ankle and reduce swelling. D: Regular assessments ensure proper circulation and monitor for complications. In summary, option B is incorrect as it goes against the principle of managing a sprained ankle in the initial phase.