A nurse has been caring for a female client who has bruises on her arms that she explains are a result of physical abuse by her husband. The client states, 'I don't know how much longer I can take this, but I'm afraid he'll really hurt me if I leave.' Which of the following is an appropriate nursing intervention?

Correct Answer: D

Rationale: The correct answer is D: Assist the client to report abusive behavior to the proper authority. This is the most appropriate intervention because it prioritizes the safety and well-being of the client. Reporting abusive behavior to the proper authority can help protect the client from further harm and connect her with resources and support services. It also empowers the client to take action to address the abusive situation. Choice A is incorrect because involving the client's husband directly may escalate the situation and put the client at further risk. Choice B is incorrect as it focuses on the client recognizing signs of escalation, rather than taking immediate action to address the abuse. Choice C is incorrect as it places the responsibility on the client to identify triggers, rather than addressing the abusive behavior directly. Reporting to the proper authority is the most effective and immediate intervention in cases of abuse.

Correct Answer: B

Rationale: The correct answer is B: An adventitious crisis. This type of crisis is caused by external events beyond a person's control, such as a natural disaster. In this scenario, Lilly's loss of her home and belongings due to the fire is an external event that led to her current state of distress. This crisis is not a result of her personal development or internal conflicts, ruling out options A, C, and D. Lilly's lack of support system and disorganization in seeking assistance further align with the characteristics of an adventitious crisis.

Correct Answer: C

Rationale: The correct answer is C: Severe anxiety. The person's symptoms indicate severe anxiety. Nausea, dizziness, tachycardia, and hyperventilation are all physical manifestations of severe anxiety. Additionally, the person's statement of feeling like something awful is going to happen, along with an inability to focus, also point towards severe anxiety. Mild anxiety typically wouldn't cause such intense physical symptoms. Moderate anxiety may cause some physical symptoms but not to the extent described in the scenario. Panic level of anxiety would usually involve more extreme symptoms such as a full-blown panic attack, which is not explicitly mentioned in the scenario.

Correct Answer: D

Rationale: The correct answer is D: Assist the client to report abusive behavior to the proper authority. This is the most appropriate intervention because it prioritizes the safety and well-being of the client. Reporting abusive behavior to the proper authority can help protect the client from further harm and connect her with resources and support services. It also empowers the client to take action to address the abusive situation. Choice A is incorrect because involving the client's husband directly may escalate the situation and put the client at further risk. Choice B is incorrect as it focuses on the client recognizing signs of escalation, rather than taking immediate action to address the abuse. Choice C is incorrect as it places the responsibility on the client to identify triggers, rather than addressing the abusive behavior directly. Reporting to the proper authority is the most effective and immediate intervention in cases of abuse.

Correct Answer: D

Rationale: The correct answer is D: Stabilize the client's physical health status. This should be done first because addressing immediate physical health needs is crucial for the client's well-being. Without stable physical health, the client may not be able to engage effectively in accessing benefits or finding safe facilities. Referring to social services (A) and discussing privacy (C) are important but secondary to addressing physical health. Providing a list of safe facilities (B) is also important but not as critical as stabilizing the client's health. By addressing physical health first, the nurse can ensure the client is in a better position to address other needs effectively.

Correct Answer: C

Rationale: The correct answer is C: cognitive behavioral therapy. This therapy focuses on changing negative thought patterns and behaviors to improve one's perceptions about life situations. It helps individuals identify and challenge irrational beliefs, leading to more positive emotions and behaviors. Milieu therapy (A) focuses on creating a therapeutic environment, not specifically on changing perceptions. Psychoanalysis (B) delves into unconscious conflicts, not necessarily focused on changing perceptions directly. Reality therapy (D) is more about personal responsibility and choices, rather than altering perceptions through cognitive restructuring.

Correct Answer: D

Rationale: The correct answer is D because communication disorders labeled as unspecified can have various causes, including genetic predisposition, environmental factors, and physical conditions. Genetic factors play a role in some communication disorders, but they are not the sole cause. Traumatic brain injury, as mentioned in choice B, is a specific cause and not applicable to unspecified disorders. Choice C is incorrect as all disorders have underlying causes, even if they are not fully understood. Choice A is also incorrect as it oversimplifies the causes of unspecified communication disorders. In summary, choice D is the most comprehensive and accurate explanation as it considers the multifactorial nature of communication disorders.

Correct Answer: A

Rationale: The correct answer is A: Panic disorder. Bipolar disorder and panic disorder commonly co-occur due to similarities in symptoms and underlying mechanisms. Both disorders involve periods of intense anxiety, fear, and impaired functioning. Research also suggests shared genetic and environmental risk factors. The other choices (B: Schizophrenia, C: Delusional disorder, D: Posttraumatic stress disorder) are less likely to be found in conjunction with bipolar disorder based on their distinct features and diagnostic criteria.

Correct Answer: D

Rationale: The correct answer is D. During termination, patients may bring up resolved issues as new concerns to prolong the nurse-patient relationship. This behavior can be a sign of attachment or fear of separation. Patients may unconsciously try to maintain connections as a means of security. Choice A is incorrect because it assumes the patient is angry, which is not necessarily the case. Choice B is incorrect as it makes an assumption about the patient's needs without evidence. Choice C is incorrect as it assumes dissatisfaction with therapy, which may not be the reason for the patient's behavior.