A client diagnosed with psychosis NOS (not otherwise specified) tells a nurse about voices telling him to kill the president. Which nursing diagnosis should the nurse prioritize for this client?

Correct Answer: C

Rationale: The correct answer is C, Risk for violence: directed toward others. This is the priority because the client is experiencing command auditory hallucinations to harm someone. The nurse must prioritize assessing and managing the risk of harm to others. Disturbed sensory perception (A) focuses on alterations in sensory input and is not the priority. Altered thought processes (B) refers to disorganized thinking and is not as critical as the risk of violence. Risk for injury (D) is too broad and does not specifically address the immediate threat of harm to others. Therefore, the nurse should prioritize addressing the potential for violence towards others to ensure the safety of the client and others.

Correct Answer: B

Rationale: The correct answer is B: Eustress. Eustress refers to positive stress that motivates an individual and enhances their performance. In this case, the patient loves their job despite its high stress nature, indicating that the stress is perceived as positive and beneficial. Distress (choice A) is negative stress that can be harmful. Psychological stress (choice C) is a broad term encompassing various stressors. Situational stress (choice D) is stress triggered by specific situations, not necessarily related to the individual's perception of the stress as positive or negative.

Correct Answer: A

Rationale: The correct answer is A: improve a patient's quality of life. Hospice care focuses on enhancing the quality of life for patients with life-limiting illnesses through holistic care, symptom management, and emotional support. This includes addressing physical, emotional, social, and spiritual needs. Providing better psychosocial care (B) is part of improving quality of life, but not the primary goal of hospice. Reducing hospital bills for families (C) is not the main purpose of hospice, as it is more about providing comfort and support rather than financial benefits. Allowing families control over decision making for alert elders (D) is important in healthcare but is not specifically related to the core purpose of hospice care.

Correct Answer: A

Rationale: The correct answer is A because self-awareness is crucial for a nurse to understand how their own beliefs may influence their interactions with clients. Researching all popular religions (B) may not be necessary for providing spiritual care. Sharing personal faith (C) can be inappropriate and imposing. Providing prayers and religious articles (D) assumes all clients share the same beliefs. Therefore, A is the best choice for starting the nurse's knowledge about spirituality.

Correct Answer: C

Rationale: The correct answer is C: Intimate. During a physical assessment, the nurse functions most often in the intimate area of the client's space, which includes areas such as the client's body and personal belongings. This is where the nurse performs tasks like taking vital signs, conducting physical examinations, and assessing for any abnormalities. The intimate space allows the nurse to gather detailed and sensitive information necessary for providing appropriate care. Choices A, B, and D are incorrect because the nurse does not primarily function in the public (Choice A), social (Choice B), or personal (Choice D) areas of the client's space during a physical assessment.