A client, age 42, has been battered by her husband since they were married 8 years ago. Until this hospitalization for major depression, she had avoided dealing with her situation, but she now expresses a desire to deal with the problem. The attacks are occurring more often. Which outcome is realistic for the client?

Correct Answer: B

Rationale: The correct answer is B: Verbalizing an awareness of her increasingly dangerous situation. This choice is the most realistic outcome for the client as it shows an initial step towards acknowledging the severity of her situation. By verbalizing awareness, the client can begin to understand the potential dangers she faces, which is crucial for developing a safety plan and seeking appropriate help. Choice A is incorrect as it may lead to victim-blaming and does not address the root cause of the abuse. Choice C is premature as setting a goal date for divorcing her husband requires careful planning and consideration of various factors. Choice D is inappropriate as retaliation can escalate the violence and put the client at further risk. In summary, choice B is the best option as it focuses on increasing the client's awareness of her situation, which is a crucial first step towards addressing and eventually overcoming the abusive relationship.

Correct Answer: B

Rationale: The correct answer is B: Bathe twice weekly with assistance. This outcome is appropriate because it takes into account the client's dementia and self-care deficit while also promoting hygiene and independence. Daily bathing may be overwhelming for the client and may not be necessary for maintaining good hygiene. Allowing the nurse to totally manage hygiene (choice C) may not promote the client's independence. Remaining free of skin diseases/lesions (choice D) is important but may not directly address the self-care deficit. Bathe twice weekly with assistance strikes a balance between promoting hygiene and respecting the client's abilities and limitations.

Correct Answer: D

Rationale: The correct answer is D: Delirium. Delirium is characterized by sudden onset confusion, disorientation, and impaired cognitive function. In this scenario, the elderly client's sudden confusion and inability to think straight suggest an acute change in mental status, which is indicative of delirium. Delirium is often triggered by underlying medical conditions or medications. A: Hallucinations involve perceiving things that are not real, which is not described in the scenario. B: Dementia is a chronic condition with gradual cognitive decline, not sudden onset confusion. C: Delusions are fixed false beliefs, which are not mentioned in the scenario. In summary, the client is most likely experiencing delirium due to the sudden onset of confusion and cognitive impairment, which is not consistent with hallucinations, dementia, or delusions.

Correct Answer: B

Rationale: The correct answer is B: Ability to perform activities of daily living. A functional assessment in home health services focuses on evaluating the client's ability to independently perform daily tasks such as bathing, dressing, and preparing meals. This assessment helps determine the client's level of independence and need for assistance. Choices A, C, and D are incorrect because they do not directly assess the client's ability to perform activities of daily living, which is the primary purpose of a functional assessment in this context.

Correct Answer: C

Rationale: The correct answer is C because disturbed thought processes indicate cognitive impairment. Thus, the expected outcome should focus on improving cognitive functioning to achieve optimal mental clarity and decision-making. Safety (A) is important but not directly related to cognitive improvement. Meeting basic needs (B) and maintaining relationships (D) are important but not the primary focus when the diagnosis is disturbed thought processes. So, the priority is on enhancing cognitive functioning to address the root cause of the issue.