A female client requests that her husband be allowed to stay in the room during the admission assessment. When interviewing the client, the RN notes a discrepancy between the client's verbal and nonverbal communication. What action does the RN take?

Correct Answer: A

Rationale: The correct answer is A: Pay close attention and document the nonverbal messages. Nonverbal communication can provide valuable insights into a client's true feelings or concerns. By observing and documenting these cues, the RN can gain a better understanding of the client's needs. This approach allows for a more holistic assessment and helps in providing individualized care. Summary: - B: Asking the client's husband to interpret the discrepancy may not be appropriate as it could breach confidentiality and may not provide accurate information. - C: Ignoring the nonverbal behavior can lead to missing important cues affecting the assessment process. - D: Integrating verbal and nonverbal messages is important, but it starts with paying close attention to and documenting nonverbal messages.

Correct Answer: C

Rationale: The correct answer is C: Ineffective breathing pattern. This is the highest priority because aspiration of a caustic material can lead to respiratory distress or compromise. Priority is given to airway and breathing concerns for immediate stabilization. Impaired comfort (A) is important but not life-threatening. Risk for injury (B) may be a concern, but airway takes precedence. Ineffective coping (D) is significant for long-term care but not immediate priority.

Correct Answer: D

Rationale: The correct answer is D because conferring with a pharmacist when selecting over-the-counter medications is crucial when taking phenelzine. This is because phenelzine is a monoamine oxidase inhibitor (MAOI) that can interact with various over-the-counter medications, leading to potentially dangerous side effects such as serotonin syndrome. Monitoring sodium intake and weight (choice A) is important for other medications but not specifically for phenelzine. Wearing support stockings and elevating legs (choice B) is not directly related to phenelzine. Identifying foods with high selenium content (choice C) is not relevant as phenelzine does not interact with selenium.

Correct Answer: A

Rationale: The correct answer is A because it indicates positive outcomes in the patient's mood and behavior. Sleeping 6 hours uninterrupted suggests improved sleep patterns, singing with an activity group shows engagement and enjoyment, and looking forward to seeing the grandchild demonstrates positive anticipation and social connection. This documentation aligns with the goals of treating major depressive disorder, which include improving sleep, increasing social interaction, and enhancing mood. Choice B is incorrect because the patient's statement about the project being a failure reflects negative self-perception, which is not indicative of treatment effectiveness. Choice C is incorrect because the patient's weight loss and need for assistance with personal hygiene suggest potential ongoing challenges and lack of improvement in self-care. Choice D is incorrect because the patient feeling tired all the time and being preoccupied with inadequacies indicate persistent symptoms of depression and lack of progress in treatment.

Correct Answer: B

Rationale: The correct answer is B: Affect flat; mood depressed. The patient's facial expression lacking emotion indicates a flat affect, while the verbal expression of feeling sad for several months indicates a depressed mood. Affect refers to the outward expression of emotion, while mood is the internal emotional state. In this scenario, the patient's flat affect and depressed mood align. Choice A is incorrect as the mood is not flat but depressed. Choice C is incorrect as the affect is not labile (fluctuating) but flat. Choice D is incorrect as the affect and mood are congruent in this case.