A patient diagnosed with depression confidently tells the nurse, “I've been supplementing my paroxetine with St. John's wort. It has helped a great deal.” What is the nurse's priority action?

Correct Answer: C

Rationale: The correct answer is C: Educate the patient about the risks of selective serotonin syndrome. St. John's wort is known to interact with many medications, including paroxetine. This combination can increase serotonin levels in the brain, leading to a potentially dangerous condition called serotonin syndrome. The nurse's priority is to ensure the patient understands this risk and the importance of consulting with their healthcare provider before combining medications. Incorrect choices: A: Assess changes in the patient's level of depression. While monitoring the patient's depression is important, addressing the potential drug interaction and safety concerns takes precedence. B: Remind the patient to use a secondary form of birth control. This is not the priority in this situation as the main concern is the drug interaction. D: Suggest adding valerian to the treatment regimen to further improve results. Introducing another supplement without addressing the potential interaction with St. John's wort and paroxetine is not appropriate.

Correct Answer: B

Rationale: The correct answer is B because involving the patient in decision making increases their sense of control and promotes adherence to treatment. By establishing a contract with the patient for a specified weekly weight gain, the patient feels empowered and motivated to actively participate in their recovery process. This sense of control can help the patient overcome resistance to weight gain and improve compliance with treatment recommendations. Explanation for other choices: A: While collecting objective and subjective data is important in managing anorexia nervosa, it does not directly address the rationale for establishing a contract with the patient. C: Consent is indeed essential for treatment, but this choice does not address the importance of patient involvement in decision making for promoting adherence to treatment. D: While a team approach to treatment planning is crucial, it does not specifically explain the rationale for establishing a contract with the patient for weight gain.

Correct Answer: C

Rationale: The correct answer is C: Trust vs. mistrust. In Erikson's theory, this stage occurs in infancy, where the primary conflict is between developing trust in others and experiencing mistrust. Mr. J.'s belief that he is being poisoned reflects a deep sense of mistrust, which aligns with the characteristics of this developmental stage. It indicates a lack of trust in his environment and possibly in his own perceptions. Choices A, B, and D do not directly address the core issue of trust and mistrust in early development, making them incorrect for this scenario.

Correct Answer: B

Rationale: The correct answer is B: Learning to delay gratification. In this stage, individuals develop impulse control and learn to consider consequences before acting. Larry's lack of guilt and disregard for others' rights indicate a failure to delay gratification, acting impulsively without regard for consequences. A: Learning to count on others focuses on developing trust in relationships, not relevant to Larry's situation. C: Identifying oneself involves establishing a sense of self and personal identity, not directly related to Larry's behavior. D: Developing skills in participation involves social interaction and cooperation, not addressing Larry's impulsivity and lack of guilt.

Correct Answer: B

Rationale: The correct answer is B: Surrogate. In this scenario, the nurse is assuming the role of a surrogate, representing the client's best interests and advocating for their well-being. The nurse is showing empathy and support by acknowledging Nancy's need for behavioral changes and expressing care. This aligns with Peplau's concept of the surrogate role, where the nurse acts as a substitute and supports the client's emotional needs. Choice A (Counselor) is incorrect because the nurse is not providing counseling or therapeutic interventions in this situation. Choice C (Technical Expert) is incorrect as the nurse is not primarily focused on providing technical knowledge or expertise. Choice D (Resource Person) is incorrect because the nurse is not primarily acting as a source of information or support for Nancy in this context.