A nurse is interviewing a client who is a survivor of abuse. The client is telling the nurse about how the violence occurred. Which statement would the nurse interpret as reflecting phase 3 of the cycle of violence?

Correct Answer: D

Rationale: Step 1: Phase 3 of the cycle of violence is the reconciliation or "honeymoon" phase where the abuser shows remorse, apologizes, and promises to change. Step 2: In choice D, the abuser apologizes and promises not to hit again, indicating the reconciliation phase. Step 3: Choices A, B, and C reflect earlier phases of the cycle - tension building (choice B) and the explosion phase (choices A and C). Step 4: In summary, choice D is correct as it aligns with the characteristics of phase 3, while choices A, B, and C represent earlier stages of the cycle of violence.

Correct Answer: A

Rationale: The correct answer is A: "How do you feel about that?" This response is nonjudgmental as it focuses on exploring the patient's feelings rather than imposing the nurse's opinion. By asking about the patient's emotions, the nurse shows empathy and encourages self-reflection. Summary of why the other choices are incorrect: B: "I am glad that you realize this." - This response implies judgment by expressing personal feelings, which may make the patient feel criticized. C: "That's not a good way to behave." - This choice is judgmental and may lead to the patient feeling defensive or ashamed. D: "Have you outgrown that type of behavior?" - This response is presumptive and also implies judgment by suggesting that the behavior should have already been outgrown.

Correct Answer: A

Rationale: The correct answer is A because the sudden onset of confusion is a key characteristic of delirium, whereas dementia typically has a gradual progression. Choice B suggests a symptom of dementia - progressive memory loss. Choice C indicates a hallucination, which can occur in both delirium and dementia. Choice D describes memory and cognitive impairment, which can be seen in both conditions but is more indicative of dementia due to the chronic nature of forgetfulness.

Correct Answer: C

Rationale: The correct answer is C because in a partial hospitalization program, the nurse's role often includes teaching patients practical skills to support their daily living. Teaching patients how to plan a menu and shop for groceries is important for promoting healthy eating habits and overall wellness. This activity directly aligns with the goal of a partial hospitalization program, which is to help patients develop skills to function independently. Choice A is incorrect because facilitating a drug abuse prevention group is more likely to be part of a substance abuse program, not a partial hospitalization program. Choice B is incorrect because providing spiritual assessment and interventions is typically the role of a spiritual care provider or counselor, not a nurse in a partial hospitalization program. Choice D is incorrect because providing an educational group about the nutritional content of canned foods is not directly related to teaching patients practical skills for daily living, which is the focus of a partial hospitalization program.

Correct Answer: A

Rationale: The correct answer is A: Glaucoma. Isosorbide mononitrate is contraindicated in patients with glaucoma due to the potential for worsening of intraocular pressure. Glaucoma is a condition where the optic nerve is damaged due to increased intraocular pressure, and isosorbide mononitrate can further elevate intraocular pressure. Choices B, C, and D are incorrect as hypertension, polycythemia, and migraine headaches are not contraindications for isosorbide mononitrate.

Correct Answer: A

Rationale: Correct Answer: A Rationale: Assessing normal sleep patterns is the initial step to understand the client's current sleep habits and identify specific disturbances in their sleep pattern. This assessment is crucial for developing an individualized care plan tailored to the client's needs. By gathering information on the client's sleep patterns, the nurse can effectively determine the underlying causes of the disturbance and implement appropriate interventions. This proactive approach ensures that interventions are evidence-based and address the client's unique situation. Summary of other choices: B: Discouraging napping during the day may be relevant but should come after assessing the client's sleep patterns to determine if daytime napping is contributing to the disturbance. C: Discouraging the use of caffeine and nicotine is important, but this intervention should be based on the assessment findings and individual client factors. D: Teaching relaxation exercises can be beneficial, but without understanding the client's specific sleep patterns and needs, it may not address the root cause of the sleep pattern disturbance.

Correct Answer: C

Rationale: The correct answer is C because family members are often the primary support system for individuals with serious mental illness. In treatment planning, involving the family can provide crucial insights into the patient's social and emotional needs, enhance communication between the patient and healthcare providers, and increase the likelihood of treatment adherence. Family support can also help in crisis situations and promote better outcomes for the patient. Choice A is incorrect because while family members may have valuable insights, they may not always know the patient's struggles comprehensively. Choice B is incorrect as willingness to listen is not a guarantee, especially in cases where mental illness may affect the patient's judgment. Choice D is incorrect as the patient may not always turn to family first, especially if the relationship is strained or if the family is not supportive.

Correct Answer: C

Rationale: The correct answer is C: functional abilities. A comprehensive geriatric assessment should focus on assessing the older adult's functional abilities to determine their ability to carry out activities of daily living independently. This is crucial in evaluating their overall health and quality of life. By assessing functional abilities, nurses can identify areas of impairment and develop appropriate interventions to maintain or improve the client's independence. Physical signs of aging (Choice A) may provide some information about the client's health status, but focusing solely on this aspect may overlook important functional deficits. Immunological function (Choice B) is important but may not be the primary focus of a geriatric assessment unless specific health concerns are present. Chronic illness (Choice D) is also important to consider but does not encompass the holistic assessment of functional abilities needed in geriatric care.

Correct Answer: D

Rationale: The correct answer is D because the patient's behavior of being tense, vigilant, pacing, clenching fists, and staring can be indicative of potential aggression. This behavior shows signs of escalating agitation and aggression, which should be addressed promptly for safety. A: Withdrawal typically involves avoiding social interactions and showing disinterest, which does not align with the patient's behavior. B: Working through angry feelings would involve more introspective or expressive behaviors, not outward signs of potential aggression. C: Relaxation strategies would involve more calming and self-soothing behaviors, which are not exhibited by the patient in this scenario.