Correct Answer: C

Rationale: The priority nursing diagnosis in this case is C: Risk for suicide. This is because the patient is exhibiting suicidal ideation, which poses an immediate threat to their safety and well-being. Suicidal ideation requires urgent intervention to ensure the patient's safety. The patient's major depression, weight gain, and lack of symptom remission from the antidepressant medication further emphasize the seriousness of the situation. Choices A, B, and D are not the priority in this scenario as they do not address the immediate risk of harm to the patient. Imbalanced nutrition and chronic low self-esteem are important concerns but do not take precedence over the risk of suicide. Hopelessness, while relevant, is not as urgent as addressing the immediate risk of suicide.

Correct Answer: D

Rationale: The correct answer is D because the inability to concentrate for extended periods is a key characteristic of ADHD. This behavior aligns with the inattention aspect of the disorder. Choice A is incorrect as separation anxiety does not directly relate to ADHD. Choice B could indicate oppositional behavior rather than ADHD. Choice C suggests sensory-seeking behavior, which is not a defining feature of ADHD.

Correct Answer: B

Rationale: The correct answer is B, clarifying with the patient whenever there is doubt. This action shows active listening, respect, and a willingness to understand the patient's needs. By seeking clarification, the nurse demonstrates genuine interest in the patient's perspective, which helps build trust. Responding positively to demands (A) may not always be appropriate or feasible. Staying available for the entire shift (C) is important but not the sole factor in trust-building. Following through with promises (D) is crucial but does not address the patient's concerns or doubts directly. Clarifying doubts fosters clear communication and mutual understanding, establishing a foundation of trust.

Correct Answer: A

Rationale: The correct answer is A because stating the goals of the group is reflective of the forming stage where members clarify the purpose and direction. Choice B is incorrect as determining leadership roles typically occurs during the storming stage. Choice C is incorrect as involving family members is not part of the group development process. Choice D is incorrect as discussing personal situations usually happens during the norming or performing stages, not in the initial forming stage.

Correct Answer: A

Rationale: Step 1: Fluid restriction of 1800 mL may not be appropriate for all residents in a skilled nursing facility. Step 2: Excessive fluid restriction can lead to dehydration, especially in elderly residents. Step 3: It is crucial for the nurse to question the fluid restriction to ensure it is safe for the resident. Therefore, the correct answer is A. Summary: - Option A is correct as questioning the fluid restriction is essential for the resident's safety. - Option B is incorrect as restraining a resident should only be used as a last resort and should be questioned if not necessary. - Option C is incorrect as blindly transcribing without assessing appropriateness can be harmful. - Option D is incorrect as assessing bowel elimination is important but addressing the fluid restriction is more urgent in this scenario.