A client with depression is not attentive to personal hygiene, uses television watching as a means of escape from responsibilities, and describes an inability to enjoy the things that once gave them pleasure. Which coping strategy should the nurse include in the plan of care?

Correct Answer: A

Rationale: The correct answer is A: Small amount of effort to solve the problem. This strategy is appropriate because it focuses on breaking down tasks into smaller, more manageable steps, which can help the client with depression feel less overwhelmed and more motivated to address personal hygiene and responsibilities. By taking small steps, the client can experience a sense of accomplishment and gradually increase their engagement in self-care activities. Option B: Encouraging the client to set daily goals may be overwhelming for someone with depression and may not address the underlying issues causing the lack of motivation. Option C: Providing opportunities for social interaction is important for overall well-being, but it may not directly address the client's specific coping needs related to personal hygiene and lack of enjoyment in activities. Option D: Teaching relaxation techniques can be helpful for managing stress and anxiety, but it may not directly address the client's lack of motivation and engagement in self-care activities.

Correct Answer: A

Rationale: The correct answer is A because attempting to physically restrain the client can escalate the situation and potentially harm the client or the mental health worker. Restraints should only be used as a last resort and under the guidance of a healthcare professional. Choice B is not ideal as it may not effectively de-escalate the situation. Choice C may further agitate the client. Choice D is not the most critical concern at the moment compared to physical restraint.

Correct Answer: A

Rationale: The correct answer is A because safety of other clients is the priority. Moving other clients to another room ensures their well-being and respects their privacy. Administering sedative medication (B) should be a last resort and requires consent. Confronting the client (C) may escalate the situation. Ignoring the behavior (D) neglects duty of care.

Correct Answer: A

Rationale: The correct answer is A because it reflects a paranoid delusion where the client believes the nurse is trying to harm him. This statement confirms the client's distorted perception of reality, a common feature of paranoid schizophrenia. Option B shows denial of illness, not delusional thinking. Option C involves persecution delusion but does not confirm the assessment. Option D indicates auditory hallucinations, not delusions. Therefore, A is the correct choice as it directly aligns with the client's paranoid delusional beliefs.

Correct Answer: A

Rationale: The correct answer is A: Monitor vital signs. This is crucial in managing a client with delirium tremens to ensure physiological stability. Monitoring vital signs such as blood pressure, heart rate, temperature, and respiratory rate can help identify any signs of deterioration or complications like dehydration, sepsis, or cardiovascular instability. By closely monitoring these parameters, the nurse can intervene promptly and prevent any further complications. Summary: - Option B is incorrect because administering antipsychotic medication is not the priority in managing delirium tremens. - Option C is incorrect as providing a quiet environment may help with managing hallucinations, but it does not address the physiological stability of the client. - Option D is incorrect as encouraging fluid intake is important for hydration but does not address the need for monitoring vital signs to ensure physiological stability.