A client on a psychiatric unit is telling the nurse about anger toward the airline after losing an only child in a plane crash. In which situation is the nurse demonstrating active listening?

Correct Answer: C

Rationale: The correct answer is C because assuming a relaxed posture and leaning toward the client demonstrates active listening by showing empathy and interest in what the client is saying. This nonverbal behavior encourages the client to continue expressing their feelings. A: Agreeing with the client can shut down communication and invalidate the client's emotions. B: Repeating everything the client says may come across as robotic and not conducive to building rapport. D: Expressing sorrow and sadness, while empathetic, may shift the focus from the client to the nurse's emotions. In summary, actively listening involves nonverbal cues that show understanding and support without interjecting personal opinions or emotions.

Correct Answer: D

Rationale: The correct answer is D: Impaired verbal communication. The patient's inability to speak, make eye contact, and focus on the speaker indicates a communication issue. Impaired verbal communication relates to difficulty expressing thoughts, feelings, or needs. The patient's behavior aligns with this diagnosis as they are mute, inattentive, and not making eye contact. Defensive coping (A) involves protecting oneself from emotional pain. Decisional conflict (B) pertains to uncertainty about choices. Risk for other-directed violence (C) involves potential harm to others, which is not evident in the scenario. Thus, D is the most appropriate nursing diagnosis.

Correct Answer: D

Rationale: The correct answer is D, teaching the person to use positive self-talk techniques. This intervention is appropriate because it addresses the cognitive aspect of anxiety. By teaching the person to challenge negative thoughts and replace them with positive affirmations, they can gradually overcome their fear and build confidence in leaving the apartment. Online video calls (A) may provide temporary relief but do not address the root cause of the anxiety. Advising the person to use a companion (B) may enable avoidance of the problem rather than actively working on overcoming it. Asking the person to explain their fear (C) may not be helpful if they are already aware that it is irrational. Positive self-talk techniques empower the individual to change their mindset and behavior effectively.

Correct Answer: C

Rationale: The correct answer is C because the patient's statement reflects a sense of acceptance and inner peace despite challenging circumstances, indicating a belief in a higher power or spirituality. This indicates that her spirituality is intact. Choice A implies social support but does not necessarily indicate spirituality. Choice B expresses hopelessness and suicidal ideation, which are not indicative of intact spirituality. Choice D reflects feelings of guilt and punishment, which do not align with a sense of spiritual well-being.

Correct Answer: A

Rationale: Correct Answer: A: Limiting amounts of evening snacks and beverages Rationale: 1. Limiting evening snacks and beverages can help regulate patients' sleep patterns by reducing stimulants that may interfere with sleep. 2. Nutrition plays a role in sleep quality, and avoiding heavy meals close to bedtime can promote better sleep. 3. This intervention addresses a common issue in psychiatric patients without imposing strict rules or physical activity. 4. It focuses on a holistic approach to improving sleep quality by considering dietary factors. Summary: B: Involving patients in a volleyball game immediately before bedtime - This choice is incorrect as vigorous physical activity before bedtime can be stimulating and may disrupt sleep. C: Enforcing the rule that all patients be in bed with lights out by 10:30 PM - This choice is incorrect as it is too rigid and may not address the underlying causes of sleep disturbances. D: Encouraging patients to take short naps in the afternoons - This choice is incorrect as daytime