A nurse is working with a patient who is in crisis. Which of the following would be least appropriate for the nurse to do?

Correct Answer: C

Rationale: The least appropriate action for the nurse is to provide false reassurance that everything will be okay. This can invalidate the patient's feelings and minimize the severity of their crisis. It's crucial for the nurse to acknowledge the patient's emotions and provide support without making unrealistic promises. Supporting cultural beliefs (A) and clarifying misconceptions (D) are important for effective communication. Encouraging the patient to focus on one aspect at a time (B) can help in breaking down overwhelming situations.

Correct Answer: D

Rationale: The correct answer is D because acknowledging a positive person in the client's life can provide emotional support and connection, which are crucial for the client's well-being after discharge. This interpersonal intervention focuses on building a supportive network for the client, enhancing their social resources and potentially reducing the risk of relapse. A, B, and C are incorrect because they primarily focus on individual insight and awareness rather than interpersonal relationships. While these interventions may be valuable in therapy, they do not directly address the importance of social support and connection, which is essential for long-term recovery and mental health stability.

Correct Answer: C

Rationale: The correct answer is C because the client stating that he feels better as he interacts more with other clients is a significant indicator of worsening suicidal risk. This change in behavior, from being consistently depressed to feeling better with social interaction, could indicate a sudden shift in mood, which may signal a potential spike in impulsivity and risk-taking behavior, including suicidal ideation. A, B, and D are incorrect: A: Expressing feeling more depressed can be a sign of deteriorating mental health, but it doesn't necessarily indicate an immediate increase in suicidal risk. B: Lethargy and isolation are common symptoms of depression and may not directly correlate with a sudden increase in suicidal risk. D: If the energy level and degree of depression remain the same, it may not indicate a worsening of suicidal risk unless other significant changes in behavior or mood are observed.

Correct Answer: D

Rationale: The correct answer is D because expressing confusion or disbelief about the death of a loved one indicates unresolved grief. A: Remembering positive memories shows acceptance. B: Engaging in new activities indicates coping and moving forward. C: Acknowledging negative traits is part of the grief process. Overall, D stands out as it shows lack of acceptance and understanding of the loss.

Correct Answer: B

Rationale: The correct answer is B: Papaverine. Papaverine is administered by injection for the treatment of erectile dysfunction. It is a smooth muscle relaxant that helps increase blood flow to the penis, improving erections. Tadalafil, Alprostadil, and Vardenafil are all administered orally and do not require injection. Tadalafil and Vardenafil are phosphodiesterase type 5 inhibitors, while Alprostadil is available in various forms such as injectable, topical, and urethral suppository, but the question specifically asks for an injection, making B the correct choice.

Correct Answer: D

Rationale: The adult in the question demonstrates positive self-esteem, feeling happy and recognizing the relationship between effort and outcomes. This aligns with Level 5 on the mental health continuum, indicating high mental health and well-being. Level 1 represents severe mental health issues, Level 2 reflects low self-esteem, and Level 3 indicates moderate mental health challenges. Therefore, the correct answer is D as it best describes the individual's positive mindset and healthy perspective on life.

Correct Answer: D

Rationale: The correct answer is D because providing culturally competent care involves identifying strategies that align with the patient's cultural context. This includes understanding the patient's beliefs, values, and practices to deliver care that is respectful and effective. Choice A focuses on interpretation rather than action. Choice B involves assumptions about individual perceptions. Choice C is about reducing ethnocentrism, which may not be the primary goal of cultural competence.

Correct Answer: B

Rationale: The correct answer is B: Risk for Injury. The priority nursing diagnosis in this scenario is based on the client's physical symptoms and potential harm to himself. The client's tremors, anxiety, elevated pulse and blood pressure, increased temperature, and diaphoresis indicate symptoms of alcohol withdrawal, which can lead to seizures or delirium tremens. The client is at risk for injury due to these physiological manifestations. Disturbed Thought Processes (A) may be present, but addressing the risk for injury takes precedence. Ineffective Coping (C) and Ineffective Denial (D) may be relevant, but they are not as urgent as ensuring the client's safety from potential harm during alcohol withdrawal.

Correct Answer: B

Rationale: The correct answer is B: Adequate reimbursement. This is the correct answer because reimbursement issues do not typically act as a barrier to pain management. It is important for healthcare professionals to provide pain management regardless of reimbursement concerns. In contrast, fear of tolerance (A), concern for being a good client (C), and reluctance to report pain (D) are common barriers to pain management that can impact patient care and outcomes. Patients may fear developing tolerance to pain medications, may be hesitant to report pain due to concerns about being seen as a difficult patient, or may simply be reluctant to report pain altogether. Addressing these barriers is crucial for effective pain management.