A nurse is working with a patient diagnosed with schizophrenia. The patient reports hearing voices and states, 'The voices tell me to hurt myself.' What is the priority nursing intervention?

Correct Answer: A

Rationale: The correct answer is A because the priority in this situation is to ensure the patient's safety. By ensuring the patient is in a safe environment and assessing for suicidal thoughts and behaviors, the nurse can prevent harm to the patient. Encouraging reality-based activities (B) and providing reassurance (C) may not address the immediate risk of harm posed by the voices. Asking about the content of the voices and validating their experiences (D) may be important for understanding the patient's perspective, but safety should come first.

Correct Answer: D

Rationale: The correct answer is D: never demonstrated. This is because the patient did not meet the desired outcome of sleeping for a minimum of 5 hours nightly within 7 days. Despite taking a 2-hour afternoon nap, the average nightly sleep is still below the target. Choice A, B, and C are incorrect because the patient did not consistently, often, or sometimes demonstrate the desired outcome as specified in the question. The key factor in determining the correct answer is comparing the actual outcome (4 hours of sleep) to the desired outcome (minimum of 5 hours of sleep).

Correct Answer: B

Rationale: Correct Answer: B Rationale: 1. Empathy: By acknowledging the patient's feelings of shame, the nurse validates their emotions and shows understanding. 2. Therapeutic Communication: Expressing empathy creates a supportive environment and encourages the patient to open up about their struggles. 3. Building Trust: Acknowledging the patient's emotions helps in building a trusting nurse-patient relationship, essential for effective care. 4. Encouraging Help-Seeking Behavior: By stating "we are here to help you," the nurse encourages the patient to seek assistance and engage in treatment. Summary: A: This response oversimplifies the issue and doesn't address the patient's emotional needs. C: Ignoring the patient's feelings and focusing solely on eating habits may be counterproductive. D: This response lacks empathy and fails to provide the necessary support for the patient's emotional well-being.

Correct Answer: C

Rationale: The correct answer is C because research indicates that spiritual practices can positively impact immune system function and coping abilities, which can help reduce the risk of infections in HIV-positive individuals. This response acknowledges the potential benefits of spiritual practices on health outcomes. Choice A is incorrect as it dismisses the potential influence of spiritual practices on health and instead attributes the patient's previous good health to youth and strength. Choice B is incorrect because it acknowledges the benefit of social support but does not directly address the potential health benefits of spiritual practices. Choice D is incorrect as it focuses solely on the risk of infections from attending church without considering the potential positive effects of spiritual practices on health.

Correct Answer: C

Rationale: The correct answer is C: Hypothalamus. The hypothalamus is responsible for regulating the autonomic nervous system, which controls involuntary responses like fear reactions. When the person with acrophobia (fear of heights) drives across the high bridge, the hypothalamus will be stimulated to trigger the autonomic nervous system's fight-or-flight response. The thalamus (A) is involved in sensory processing, the parietal lobe (B) in spatial awareness, and the pituitary gland (D) in hormone regulation - none of which directly relate to the autonomic nervous system's response to fear stimuli.