A client states she is hearing voices that tell her to cut herself. She already has several superficial marks on her wrists from scratching herself with the plastic eating utensils. She will not contract for safety. What is the priority nursing intervention?

Correct Answer: C

Rationale: The correct answer is C: Place on one-on-one, constant observation to ensure she does not harm herself. This is the priority nursing intervention because the client is at high risk for self-harm, as evidenced by hearing voices telling her to cut herself and already having marks on her wrists. Since she will not contract for safety, one-on-one observation is necessary to prevent harm. Removing plastic utensils (choice A) may not be sufficient to prevent self-harm. Conducting 15-minute checks (choice B) is not appropriate given the level of risk. Seclusion (choice D) is a restrictive intervention and should only be used as a last resort when less restrictive measures are insufficient. Constant observation ensures immediate intervention if self-harm is attempted, making it the most appropriate intervention in this scenario.

Correct Answer: B

Rationale: The correct answer is B: "If I don't do intravenous (IV) drugs anymore, God won't let me die." This statement reflects the bargaining stage of grief, where the individual tries to negotiate with a higher power to avoid the negative outcome. It shows a sense of trying to control the situation through a specific action. In contrast, choices A, C, and D do not demonstrate bargaining behavior. Choice A expresses anger and blame, not bargaining. Choice C shows acceptance and proactive behavior, not bargaining. Choice D reflects denial or disbelief in the diagnosis, not bargaining.

Correct Answer: C

Rationale: The correct answer is C: The client snaps at the nurse and criticizes the nursing care provided. Displacement is a defense mechanism where emotions are redirected from the original source to a less threatening target. In this case, the client's frustration towards the healthcare provider's diet plan is displaced onto the nurse, leading to snapping and criticizing the nursing care. This behavior allows the client to express their anger indirectly. Incorrect choices: A: The client assertively confronts the health-care provider. This is not an example of displacement; it is direct confrontation. B: The client insists on being discharged and goes for a long, brisk walk. This choice does not demonstrate displacement but rather avoidance of the situation. D: The client hides his anger by explaining the logical reasoning for the diet to his spouse. This choice does not involve displacement but rather rationalizing the situation to cope with anger.

Correct Answer: C

Rationale: The correct answer is C because the statement indicates that the wife has gained insight and reflection on the experience, showing acceptance. Choice A reflects regret and longing for reconciliation, not acceptance. Choice B demonstrates anger and resentment, not acceptance. Choice D suggests ongoing distress and difficulty coping, not acceptance. Acceptance involves acknowledging the reality of the situation, learning from it, and moving forward positively.

Correct Answer: A

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.