A confused older adult patient in a skilled nursing facility was asleep when unlicensed assistive personnel (UAP) entered the room quietly and touched the bed to see if it was wet. The patient awakened and hit the UAP in the face. Which statement best explains the patient's action?

Correct Answer: D

Rationale: The correct answer is D because the patient's action can be explained by the concept of interpreting the UAP's behavior as potentially harmful. In this scenario, the patient was asleep and suddenly awakened by the UAP quietly entering the room and touching the bed. The patient's instinctive response of hitting the UAP in the face can be seen as a defensive reaction triggered by perceiving a potential threat or harm from the UAP's unexpected actions. This aligns with the idea that older adults in a vulnerable state may react aggressively when feeling threatened or unsafe. Choice A is incorrect because it generalizes behavior without considering the specific context of the situation. Choice B is incorrect as it does not directly address the patient's perception of harm from the UAP's actions. Choice C is incorrect as there is no evidence provided in the scenario to support the idea that the patient learned violent behavior from other patients.

Correct Answer: D

Rationale: The correct answer is D: "What gives your life meaning?" because it directly relates to assessing the patient's spirituality by exploring their values, beliefs, and purpose in life. This question allows the nurse to understand the patient's spiritual perspective and connection to something greater than themselves. Choice A is incorrect because it focuses on mental health and suicide risk rather than spirituality. Choice B is also incorrect as it emphasizes the importance of family rather than exploring the patient's spiritual beliefs. Choice C is incorrect as it delves into moral philosophy rather than directly addressing the patient's spirituality. By asking about the meaning in life, the nurse can gain insight into the patient's spiritual well-being and provide appropriate support.

Correct Answer: B

Rationale: The correct answer is B: New members are added by birth, marriage, or adoption. This is because families are not solely defined by blood relations but also by relationships formed through birth, marriage, or adoption. This inclusive definition reflects the diverse structures of modern families. Choice A is incorrect as it limits the definition of families to blood relations only. Choice C is incorrect as family size trends vary and may not necessarily be increasing in the United States. Choice D is incorrect as families today are often more mobile due to various factors such as job opportunities and lifestyle choices.

Correct Answer: C

Rationale: The correct answer is C: Compassion. Compassion is the emotion associated with being moved by another's suffering and wanting to help. It involves recognizing and empathizing with someone else's pain and feeling motivated to alleviate that suffering. Relief (A) is the feeling of release from stress or anxiety, not necessarily related to helping others. Hope (B) is the feeling of optimism and expectation for a positive outcome, not specifically related to being moved by another's suffering. Love (D) is a complex emotion involving deep affection and attachment, but it may not always lead to the desire to help alleviate someone else's suffering, unlike compassion.

Correct Answer: A

Rationale: The correct answer is A: Clang association. Clang association is a form of disorganized speech commonly seen in schizophrenia where words are linked together based on sound rather than meaning. In this scenario, the client is stringing together words that rhyme, indicating a pattern based on sound. Stilted language refers to formal, rigid speech lacking natural flow. Verbigeration is the repetition of words or phrases. Neologisms are newly created words. In this case, the client's speech does not fit the definitions of stilted language, verbigeration, or neologisms, making clang association the most appropriate choice.