A nurse has formulated several nursing diagnoses for a homeless client after a thorough nursing assessment. Of these, which of the following would the nurse determine as the priority?

Correct Answer: C

Rationale: The correct answer is C: Imbalanced nutrition. This is the priority because it addresses the client's physiological needs, which are essential for survival and overall well-being. The nurse should prioritize addressing basic needs such as nutrition before addressing psychological or social needs. Anxiety (A), powerlessness (B), and impaired social interaction (D) are important but secondary to addressing the client's immediate physiological needs. It is important to address the most critical issue first to ensure the client's health and safety.

Correct Answer: D

Rationale: The correct answer is D: "Would you like to play a game of checkers with me?" This choice is most appropriate as it focuses on building a therapeutic relationship through a non-threatening and engaging activity. Playing a game of checkers can help establish rapport, foster trust, and create a sense of normalcy for the child in a psychiatric setting. It allows for social interaction, provides a distraction, and can help the child feel more comfortable and open up to the nurse. Explanation of why the other choices are incorrect: A: Comparing the child's situation to Cinderella's in a fairy tale may not be relatable or relevant to the child's experiences, potentially minimizing their feelings and concerns. B: Using a tool to measure self-control and initiative may come off as clinical and impersonal, possibly making the child feel like they are being evaluated rather than supported. C: Asking the child to draw a picture of themselves may be intimidating or invasive, as it delves into personal expression without

Correct Answer: A

Rationale: The correct answer is A: safety and quality improvement. Hand hygiene surveillance project aligns with safety by preventing infections and quality improvement by enhancing patient outcomes. Safety includes preventing harm, while quality improvement focuses on optimizing processes. Teamwork (B) and informatics (C) are not directly related to hand hygiene surveillance. Evidence-based practice (D) and person-centered care (D) are important but not the primary focus of a hand hygiene surveillance project.

Correct Answer: C

Rationale: The correct answer is C: Imbalanced nutrition. This is the priority because it addresses the client's physiological needs, which are essential for survival and overall well-being. The nurse should prioritize addressing basic needs such as nutrition before addressing psychological or social needs. Anxiety (A), powerlessness (B), and impaired social interaction (D) are important but secondary to addressing the client's immediate physiological needs. It is important to address the most critical issue first to ensure the client's health and safety.

Correct Answer: C

Rationale: The correct answer is C: Using a future-oriented goal focus. In cognitive behavior therapy, focusing on future-oriented goals helps the patient set achievable objectives and work towards positive outcomes. This approach encourages the patient to look forward and make changes that align with their desired future. Establishing the agenda (A) can be helpful but may not be as effective as focusing on goal setting. Focusing primarily on behavior (B) is too narrow and may not address the underlying thoughts and emotions. Identifying the problem from the nurse's perspective (D) is not client-centered and may not promote active participation in the therapy process.