A nurse is preparing a plan of care for a client diagnosed with body dysmorphic disorder. Which nursing diagnosis would the nurse most likely identify as the priority?

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: B

Rationale: The correct answer is B because it highlights the importance of checking for congruence between verbal and nonverbal communication to validate responses. This demonstrates an understanding that nonverbal cues can provide additional insights into a patient's true feelings or thoughts. Choice A is incorrect as it simply states a general observation without emphasizing the significance of nonverbal cues. Choice C is incorrect because assuming a patient's emotions based solely on body posture is not accurate or reliable. Choice D is incorrect as it undervalues the importance of nonverbal communication in understanding the complete message being conveyed.

Correct Answer: B

Rationale: The correct answer is B because assessing alcohol and tobacco use in a pregnant client with depression is crucial for providing comprehensive care. First, substance use can exacerbate mental health symptoms and impact treatment effectiveness. Second, substance use during pregnancy can harm both the mother and the unborn child, leading to adverse health outcomes. Third, this information is vital for developing a holistic care plan that considers both the mental health needs of the client and the safety of the unborn child. Choices A, C, and D are incorrect because: A: Failing to assess alcohol and tobacco use neglects essential information that can impact the client's well-being and treatment. C: Substance use during pregnancy can have significant long-term effects on the unborn child's health and development. D: Assessing alcohol and tobacco use is not optional, as it directly influences the client's mental health and the well-being of the unborn child.

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: 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: 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: C

Rationale: The correct answer is C: "We've installed locks on all the outside doors." This statement shows an understanding of the need to prevent the patient with dementia from wandering off and getting lost or injured. Installing locks on outside doors helps to ensure the patient's safety by limiting their ability to leave the house unsupervised. This measure is crucial in providing a secure environment for someone with dementia. Explanation: A: The statement about the local police knowing the patient has wandered off before does not address the immediate need to prevent wandering and ensure safety. B: Keeping the noise level low in the house may be helpful for a patient with dementia, but it does not directly address the safety concern of wandering. D: Attaching the telephone number to the patient's shirt pocket is a good safety measure, but it does not address the primary concern of preventing the patient from wandering off.