A patient, aged 82 years, has Alzheimer's disease. She lives with her daughter's family and goes to a day care facility on weekdays. The family cares for her during the evening and at night. Noting the patient had several bruises, the nurse discussed her observations with the daughter, who became defensive and said that her mother was very difficult to manage because she is confused and wanders all night. She says the bruises resulted from a fall down stairs. The daughter states, "I have lost my mother, and I cannot bear it anymore. It is wrecking my family." The nursing intervention that should take priority is:

Correct Answer: B

Rationale: The correct answer is B: Identifying two options for caregiver respite and care assistance at night. This is the priority intervention because it addresses the immediate need to ensure the patient's safety and well-being while also supporting the daughter who is struggling to cope. By identifying options for caregiver respite and care assistance at night, the daughter can get the help she needs to manage her mother's care effectively without feeling overwhelmed. This intervention promotes both the patient's safety and the daughter's mental well-being. Choices A, C, and D are incorrect: A: Teaching the daughter more about the effects of Alzheimer's disease. While education is important, in this scenario, the immediate need is to address caregiver respite and care assistance. C: Supporting the daughter to grieve the loss of her mother's ability to function. While supporting the daughter emotionally is important, ensuring the patient's safety should take priority. D: Teaching the family how to give physical care more effectively and efficiently. While this is important

Correct Answer: B

Rationale: The correct answer is B because providing written information about physical and emotional reactions respects the individual's autonomy and empowers them to make informed decisions. It also ensures they have resources to understand and cope with potential consequences. Choice A violates the individual's right to refuse treatment. Choice C focuses on specific tests without addressing the person's immediate concerns. Choice D, while important, is not as immediate or relevant as providing information on potential reactions.

Correct Answer: D

Rationale: The correct answer is D because mandatory reporting laws typically require healthcare professionals to report suspected cases of child abuse or neglect. Having suspicions that abuse has occurred is sufficient to make a report, as it is the responsibility of the healthcare provider to protect the child's safety. Obtaining the supervisor's permission (choice A) may delay the report unnecessarily. Having strong evidence (choice B) is not necessary for making a report, as suspicions should be reported for further investigation. Notifying the parents (choice C) may jeopardize the safety of the child if the abuser is aware of the report.

Correct Answer: B

Rationale: The correct answer is B: "Could we talk about developing a safety plan?" This response is the best choice as it acknowledges the woman's situation, offers support, and focuses on practical steps to ensure her safety. By suggesting a safety plan, the nurse is addressing the immediate concern of potential harm and empowering the woman to take control of her situation. Incorrect Choices: A: This response is too direct and may not take into account the complexities of the woman's situation. It lacks empathy and does not offer a constructive solution. C: This response shifts the focus away from the woman's safety and onto external factors. It may come across as judgmental and unhelpful. D: This response is dismissive and fails to acknowledge the seriousness of the situation. It does not offer any support or guidance to the woman in need.

Correct Answer: A

Rationale: The correct answer is A: Disturbed thought processes. This nursing diagnosis is appropriate because the client's symptoms suggest cognitive impairment and delusions, which are common in dementia. The client's accusations of theft and imprisonment indicate a distortion in reality perception, reflecting disturbed thought processes. Powerlessness (B) relates more to lack of control over circumstances, not cognitive issues. Ineffective coping (C) and Defensive coping (D) focus on emotional responses rather than cognitive impairment.