A client, age 70, was brought into the Emergency Department by family members who reported a fall. During the assessment, the nurse became suspicious that the client had suffered physical abuse. The client denied that she had been abused. Her denial is most likely based on her:

Correct Answer: B

Rationale: The correct answer is B: Emotional response to the situation. The client's denial is likely due to emotional factors such as shame, embarrassment, or fear of causing trouble for family members. This emotional response can lead the client to deny abuse even when it has occurred. Choice A is incorrect because fear of retaliation may be a factor, but emotional response is more likely. Choice C is incorrect as cognitive impairment would affect the client's ability to understand and respond to the situation, not necessarily lead to denial. Choice D is incorrect as the client's denial is influenced by emotional factors.

Correct Answer: A

Rationale: The correct answer is A because the goal in managing delirium in an elderly patient is to restore them to their premorbid level of functioning. This involves addressing the underlying causes like fever and dehydration. Option B is incorrect as it focuses on a neurological response rather than the overall outcome for the patient. Option C is also incorrect as it pertains to identifying stressors, which is not the primary goal in managing delirium. Option D is incorrect as it dismisses the importance of restoring the patient to their baseline level of functioning.

Correct Answer: B

Rationale: Correct Answer: B - Patient involvement in decision-making increases sense of control and promotes collaboration. Rationale: 1. Involving the patient in decision-making empowers them and increases their sense of control over their treatment. 2. Collaborating with the patient fosters a positive therapeutic relationship. 3. This approach is more likely to lead to better treatment adherence and outcomes. Summary: A: While objective and subjective data are important, this choice does not address the need for patient involvement in decision-making and collaboration. C: The lack of family support is not directly related to the rationale for establishing a contract with the patient. D: This choice is incorrect as patient involvement is crucial in promoting successful treatment outcomes.

Correct Answer: D

Rationale: The correct answer is D: None of the above. Sleep terrors are not typically accompanied by intense stress, sexual arousal, or increased physical strength. Sleep terrors are characterized by sudden awakening from sleep with intense fear and a physical reaction, such as screaming or thrashing. These episodes occur during stages 3 and 4 of NREM sleep and are not associated with the physical signs mentioned in the other choices. Therefore, the correct answer is D, as sleep terrors do not necessarily involve any of the physical signs listed in the other options.

Correct Answer: B

Rationale: Step-by-step rationale: 1. Maintaining a healthy, balanced diet without purging behaviors is crucial for managing bulimia nervosa. 2. This goal promotes physical health and addresses the underlying disordered eating habits. 3. It focuses on establishing sustainable eating patterns to support overall well-being. 4. It helps prevent complications associated with bulimia, such as electrolyte imbalances. Summary: - Option A is incorrect as excessive exercise can be a compensatory behavior in eating disorders. - Option C is incorrect as rapid weight gain is not recommended in the treatment of bulimia. - Option D is incorrect as complete elimination of binge eating and purging may be unrealistic initially.