A nurse is developing a care plan for a client with post-traumatic stress disorder. Which of the following should be completed first?

Correct Answer: A

Rationale: The correct answer is A because encouraging the client to verbalize thoughts and feelings about the trauma is a crucial first step in addressing post-traumatic stress disorder. This allows the client to process and express their emotions, which can help in reducing the intensity of symptoms and promoting healing. Choice B is incorrect as distraction techniques may provide temporary relief but do not address the underlying issues. Choice C is incorrect as putting the past in proper perspective may be a long-term goal but is not the first step in care. Choice D is incorrect as avoiding discussing the traumatic events can hinder the client's progress in therapy.

Correct Answer: C

Rationale: The correct answer is C: "I will be glad to assist. I'll be right back with your supplies." This response acknowledges the client's request for assistance with empathy and reassurance. By stating "I'll be right back with your supplies," the nurse communicates readiness to help promptly. Option A is insensitive and dismissive of the client's emotions. Option B implies that the client's appearance is the root cause of their emotional state. Option D assumes the client's motivation for showering is to please their spouse, which may not be the case. Overall, option C demonstrates empathy, willingness to help, and respect for the client's autonomy.

Correct Answer: B

Rationale: The correct answer is B. Ensuring the child does not receive an injury from body movements is the best nursing action because safety is the top priority when dealing with a child exhibiting self-injurious behaviors like headbanging and spinning. By preventing injuries, the child's well-being is prioritized. Choice A is incorrect because instructing the child to follow directions may not be effective if the child is non-responsive due to their autism spectrum disorder. Choice C is incorrect as placing the child in seclusion is not recommended for managing behaviors related to autism spectrum disorder. It does not address the underlying cause and can lead to further distress. Choice D is incorrect as showing the child how to maintain eye contact may not be feasible or effective at that moment, especially if the child is exhibiting self-injurious behaviors.

Correct Answer: C

Rationale: The correct answer is C. Physical neglect is characterized by a lack of adequate care or supervision, resulting in a child's basic needs not being met. The assessment data provided in choice C, such as frequent absences, dirty clothes, withdrawal, and fatigue, are indicators of physical neglect. Absences may be due to lack of attention to the child's well-being, dirty clothes suggest poor hygiene care, and withdrawal and tiredness can stem from emotional neglect and lack of proper nutrition or sleep. Choices A, B, and D are not indicative of physical neglect. Choice A relates to sexual behavior knowledge, choice B to emotional well-being, and choice D to physical abuse.

Correct Answer: C

Rationale: The correct answer is C: Place on one-on-one, constant observation to ensure she does not harm herself. This is the priority nursing intervention because the client is at high risk for self-harm, as evidenced by hearing voices telling her to cut herself and already having marks on her wrists. Since she will not contract for safety, one-on-one observation is necessary to prevent harm. Removing plastic utensils (choice A) may not be sufficient to prevent self-harm. Conducting 15-minute checks (choice B) is not appropriate given the level of risk. Seclusion (choice D) is a restrictive intervention and should only be used as a last resort when less restrictive measures are insufficient. Constant observation ensures immediate intervention if self-harm is attempted, making it the most appropriate intervention in this scenario.