A new nurse asks the experienced nurse who is caring for a battered woman client, 'Why did you ask about culture when it was obvious you needed to focus on the battering?' The experienced nurse should respond:

Correct Answer: C

Rationale: Rationale: - Choice C is correct because culture influences how individuals perceive and respond to violence, impacting their help-seeking behaviors and coping mechanisms. - Understanding the client's cultural background is crucial for providing appropriate care and support. - Choices A, B, and D are incorrect as they do not address the importance of considering culture in understanding and addressing domestic violence in this context.

Correct Answer: B

Rationale: The correct answer is B because maintaining hydration and nutrition is crucial for the client's overall well-being and health in stage 3 Alzheimer's. Dehydration and malnutrition can lead to serious complications. Providing a stimulating environment (choice A) may be beneficial but not the highest priority. Setting limits on behavioral disinhibition (choice C) may be challenging due to the progression of the disease. Promoting self-care activities (choice D) may not be feasible as the client's cognitive abilities decline. Maintaining hydration and nutrition is essential for the client's survival and quality of life.

Correct Answer: A

Rationale: The affective losses of Alzheimer's disease refer to changes in emotions and mood, impacting personality traits. This is because the disease affects areas of the brain responsible for regulating emotions. Personality changes are commonly observed in individuals with Alzheimer's. Thought processes (choice B) are more related to cognitive decline, while ability to make and carry out plans (choice C) and self-care (choice D) are more associated with functional decline. Therefore, choice A is correct as it specifically addresses the affective aspect of the disease.

Correct Answer: D

Rationale: The correct answer is D: She has taken any over-the-counter medications for her cold. It is important for the nurse to ask this question because over-the-counter medications can sometimes interact with prescription medications, leading to confusion or other cognitive issues in elderly patients. By identifying any OTC medications the client has taken, the nurse can assess potential drug interactions that may be contributing to the confusion. Choices A, B, and C are incorrect. History of mental illness in the family or a previous diagnosis of mental health disorder may not directly address the current issue of confusion related to medication management. Asking about the last visit to a physician is also less relevant compared to inquiring about current medication use for a potential cause of confusion.

Correct Answer: A

Rationale: The correct answer is A: Crisis intervention. This is appropriate because the child is experiencing multiple stressors that require immediate support. Crisis intervention focuses on providing immediate assistance to individuals in distress and can help address the child's current emotional and psychological needs. Summary of other choices: B: Creating a safety plan may be relevant if there are safety concerns, but it does not address the child's emotional well-being. C: Referring to family therapy may be beneficial in addressing family dynamics, but it may not be the most urgent intervention in this case. D: Referring for case management is important for coordinating services, but it may not provide the immediate emotional support needed in this situation.