A nurse is assisting a client with borderline personality disorder in how to manage transient psychotic episodes that involve auditory hallucinations. The teaching is planned for times when the client is free of these symptoms. Which of the following would the nurse instruct the client to do first?

Correct Answer: C

Rationale: The correct answer is C: Identify early internal cues of distress. This is the first step because recognizing early signs of distress can help the client intervene before the psychotic episode escalates. By identifying these cues, the client can implement coping strategies and prevent the hallucinations from worsening. Explanation for incorrect choices: A: Using skills to tolerate painful feelings is important, but identifying early cues is crucial for early intervention. B: Deep abdominal breathing can help with relaxation, but it may not address the underlying distress leading to the hallucinations. D: Referring to cards listing symptoms is less effective as it focuses on recognizing symptoms rather than proactively managing distress cues.

Correct Answer: A

Rationale: The correct answer is A: "Has your father taken any medications recently?" This question is most appropriate because delirium can be caused by medication side effects. By asking about recent medications, the nurse can gather important information to help identify potential causes of the client's delirium. Summary of other choices: B: "Are you aware of your father falling or injuring his head in any way?" - This question focuses on physical trauma, which may not necessarily be related to the client's delirium. C: "Has your father had a recent stroke?" - While a stroke can cause delirium, assuming a stroke without evidence may lead to incorrect assessment and treatment. D: "Has your father experienced any major losses recently?" - This question is more related to emotional stressors and may not directly address the potential medical causes of delirium.

Correct Answer: B

Rationale: The correct answer is B: Description of information about pertinent legal and court proceedings that are pending. Rationale: Understanding legal and court proceedings is crucial for a forensic client as it directly impacts their current situation and future outcomes. Providing this information can empower the client to make informed decisions and actively participate in their legal process, promoting autonomy and self-advocacy. Summary: A: While genetic and neurologic factors can contribute to criminal behavior, focusing solely on these aspects may not be the most immediate concern for the client's current needs. C: Nutrition and exercise are important for overall well-being but may not be the top priority when dealing with legal matters. D: Connecting the client's family to community providers is beneficial, but understanding legal proceedings is more urgent for the client's immediate needs.

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Assess AP's qualifications: Ensures competency and safety. 2. Delegation based on competence: AP must be capable. 3. Legal and ethical responsibility: Nurse is accountable for delegation. 4. Ensures client safety: Properly trained AP will perform test accurately. Summary: B: Nurse should not perform the test; delegating responsibility is key. C: Asking about medication is not within scope for blood glucose testing. D: Checking prior results is not necessary for performing a current test.