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: D

Rationale: The correct answer is D because hearing evil voices indicating potential psychosis or severe mental health issues requiring immediate attention. This statement suggests possible hallucinations and command hallucinations that pose a risk to the individual and others. It should be the priority focus for the plan of care. A: Trusting family is important but does not indicate immediate safety concern. B: Perception of bad luck may be relevant but not as urgent as potential hallucinations. C: Concern about betrayal is significant but does not pose an immediate risk compared to hearing evil voices.

Correct Answer: D

Rationale: Rationale: - The correct answer is D because monitoring weight changes is crucial in the early stages of SSRI treatment, as weight gain could be a side effect. - A is incorrect because SSRIs do not typically affect fluid intake. - B is incorrect because abruptly stopping an SSRI can lead to withdrawal symptoms and should only be done under medical guidance. - C is incorrect as menstrual irregularities are not a common side effect of SSRIs. Summary: Monitoring weight changes is essential when taking SSRIs to address potential side effects. Other choices are incorrect as they do not align with the usual considerations for SSRI treatment.

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 because it reflects the negative outcome of despair in Erikson's stage of "old age." In this stage, individuals reflect on their lives and may feel satisfied or dissatisfied. Option D shows the woman feeling anger and dissatisfaction, indicating despair. Choice A involves a woman struggling with caregiving, which could be a challenge but doesn't necessarily reflect despair. Choice B describes someone reflecting on their life, which is a positive aspect of this stage. Choice C shows a man openly discussing his accomplishments and failures, which is a healthy way of coping and doesn't indicate despair.