A nurse is assessing a client who is a survivor of abuse. Which of the following would be most appropriate to use when conducting a lethality assessment?

Correct Answer: A

Rationale: The correct answer is A: Danger Assessment Screen. This tool is specifically designed to assess the risk of lethality in individuals who have experienced abuse. It includes questions related to the severity and frequency of abuse, as well as other risk factors such as access to weapons and history of threats. It helps identify clients at high risk of harm or death. B: Abuse Assessment Screen is a screening tool to identify abuse but does not specifically focus on lethality risk. C: Burgess-Partner Abuse Scale is a measure of the frequency and severity of intimate partner violence, but it does not assess lethality risk. D: Beck Depression Inventory is a tool to assess the severity of depression and is not designed to evaluate the risk of harm or death in abuse survivors.

Correct Answer: D

Rationale: The correct answer is D because assessing the client's ability to go to the store and buy groceries directly evaluates their instrumental activities of daily living (IADLs), which are crucial for independent living. This question helps determine the client's mobility, cognitive function, and ability to manage finances and nutrition. Choices A and B focus more on basic activities of daily living (ADLs) related to personal hygiene and clothing changes. Choice C is related to cooking meals, which is also an IADL but may not provide as comprehensive information about the client's overall independence compared to the ability to shop for groceries.

Correct Answer: D

Rationale: The correct answer is D: "You may feel dizzy and be prone to falls after taking this medication." Rationale: 1. Diazepam (Valium) is a benzodiazepine known to cause dizziness and drowsiness as common side effects. 2. Dizziness can increase the risk of falls, especially in older adults who may already have balance issues. 3. Falls can lead to serious injuries in older adults, making it crucial for the nurse to emphasize this risk. 4. Minor urine incontinence (choice A) is not a common side effect of diazepam. 5. Temporary memory disturbances (choice B) are possible but not as critical as the risk of falls. 6. Dependence (choice C) is a potential issue with benzodiazepines but may not be the most immediate concern in this scenario.

Correct Answer: B

Rationale: The correct answer is B: Assessment. In the Calgary Family Model, the Assessment stage involves identifying and understanding the problems within the family system. This is where the nurse gathers information about the family's strengths, resources, and challenges. The nurse assesses the family's structure, communication patterns, roles, and interactions to develop a comprehensive understanding of the family dynamics. Engaging with the family (Choice A) occurs before the Assessment stage. Intervention (Choice C) comes after the Assessment stage when specific strategies are implemented. Termination (Choice D) is the final stage when the nurse concludes their work with the family.

Correct Answer: A

Rationale: The correct answer is A: Disturbed Body Image. This is the priority nursing diagnosis for a client with body dysmorphic disorder because it directly addresses the client's preoccupation and distress related to perceived flaws in appearance. By addressing the disturbed body image, the nurse can help the client work through these feelings and improve self-perception. Choice B: Ineffective Coping may be relevant but addressing the underlying body image distortion is crucial. Choice C: Low Self-Esteem is a common issue with body dysmorphic disorder but improving body image perception is more specific. Choice D: Risk for Other-Directed Violence is not directly related to body dysmorphic disorder symptoms. In summary, addressing the core issue of distorted body image is the priority in caring for a client with body dysmorphic disorder.

Correct Answer: D

Rationale: The correct answer is D because the patient's action of pulling out a knife and making a threat demonstrated a clear and present danger to others. The patient's behavior posed an immediate risk to the safety of those around them, necessitating urgent intervention for the protection of others. A: While the patient was indeed threatening to others, the severity of the threat, involving a weapon, indicated a higher level of danger. B: Psychosis alone may not always indicate an immediate danger to others unless accompanied by specific threatening behavior. C: While escape risk is a consideration, the primary concern in this scenario was the patient's potential harm to others, justifying seclusion for safety reasons.

Correct Answer: D

Rationale: The correct answer is D: transition of care. Transition of care refers to clients moving between treatment settings, ensuring continuity and coordination of care. Rehospitalization (A) specifically refers to clients being admitted back to the hospital. Adverse event (B) refers to harm resulting from medical care. Readmission (C) is similar to rehospitalization, specifically indicating clients being admitted back to a hospital after a previous discharge. Transition of care (D) is the most appropriate term as it encompasses the movement of clients between various healthcare settings beyond just hospitals.

Correct Answer: D

Rationale: Reaction formation is a defense mechanism where a person behaves in a way that is opposite to their true feelings or impulses. In this scenario, choice D demonstrates reaction formation because the client is expressing a belief that people who steal are lazy and should earn money honestly, which is opposite to their own behavior of stealing. This behavior helps the client deny their true feelings of guilt or shame about their actions. Choices A, B, and C do not exhibit reaction formation as they do not involve expressing beliefs or behaviors opposite to their true feelings or impulses.

Correct Answer: B

Rationale: The correct answer is B, management of milieu safety. This is because the nurse's observations pertain to ensuring a safe and secure environment within the psychiatric unit. Checking for unobstructed exits, no smoking, and a locked janitor's closet are all crucial aspects of maintaining a safe milieu for patients. A: Coordinating care of patients is not directly related to the observations mentioned. C: Management of the interpersonal climate focuses on relationships and communication among patients and staff, not physical safety measures. D: The use of therapeutic intervention strategies involves treatment modalities and interventions for patient care, which is not the primary focus of the nurse's observations.