A patient has threatened to kill his wife, and it is not anticipated that this crisis will resolve itself. The patient is to be admitted to an inpatient psychiatric unit on an involuntary basis. When explaining to the family about this plan, the nurse would identify which of the following as the focus of care?

Correct Answer: C

Rationale: The correct answer is C: Acute symptom stabilization. In this situation, the main focus of care is to address the immediate threat of harm to the patient's wife by stabilizing the patient's acute symptoms. This involves ensuring the patient's safety and the safety of others through interventions such as medication management and behavioral interventions. Long-term therapy (choice A) would not be the immediate priority, as the focus is on managing the current crisis. Rehabilitative services (choice B) focus on long-term recovery and functioning, which is not the primary goal at this stage. 24-hour supervision (choice D) may be necessary as part of the care plan, but it is not the primary focus of care in this scenario.

Correct Answer: A

Rationale: The correct answer is A: Risk for falls R/T right-sided weakness and sedation from risperidone. This is the priority nursing diagnosis because the client's physical aggression and right-sided weakness increase the risk of falls, which can lead to further injury. The sedative effect of risperidone can further impair the client's balance and coordination, exacerbating the risk. Addressing this risk is crucial to ensure the safety and well-being of the client. Summary of other choices: B: Activity intolerance R/T right-sided weakness - While this is a relevant concern, it is not the priority as the risk of falls takes precedence. C: Disturbed thought processes R/T acting-out behaviors - While the client's behavior may be a concern, addressing the immediate risk of falls is more critical. D: Anxiety R/T change in health status and dependence on others - While anxiety may be present, addressing the risk of falls is more urgent in this situation.

Correct Answer: D

Rationale: The correct answer is D: Glass of milk. Milk contains tryptophan, an amino acid that helps in the production of serotonin, a neurotransmitter that contributes to mood regulation. Offering the patient a glass of milk can help increase serotonin levels, potentially decreasing irritability. A: Chocolate candy bar is high in sugar and may lead to a spike in blood sugar levels, followed by a crash, which can worsen irritability. B: Raisins are a source of natural sugars but lack the necessary nutrients to help regulate mood. C: Granola bar may contain added sugars and lack the specific components like tryptophan found in milk to help improve mood.

Correct Answer: B

Rationale: The correct answer is B. By informing the student's instructor and the client's primary nurse, the nursing student upholds the ethical principle of veracity, which is being truthful and honest. This action ensures that the correct dosage of medication is administered to the client, preventing potential harm. Documenting the situation is essential for accurate record-keeping and accountability. Choice A is incorrect because keeping the information confidential would go against the ethical principle of veracity and could potentially harm the client. Choice C is incorrect as the decision about actions should involve healthcare professionals to ensure the client's safety and well-being, not solely the client. Choice D is incorrect because even if the client was not harmed immediately, incorrect medication dosages could still have long-term consequences, making it crucial to report the incident for proper evaluation and prevention.

Correct Answer: D

Rationale: The correct answer is D because reminiscence involves encouraging individuals to recall past events, which can help trigger memories and improve cognitive function in Alzheimer's patients. By encouraging the residents to talk about pleasurable past events, Ling is engaging them in reminiscence therapy, which can enhance their well-being and quality of life. Option A is incorrect because talking about Ling's own grandparents' lives doesn't directly engage the residents in reminiscing about their own past. Option B is incorrect because playing music from the residents' formative years may evoke memories but does not actively engage them in reminiscence therapy. Option C is incorrect because reviewing movies may provide entertainment but does not specifically target reminiscence and memory recall as effectively as encouraging the residents to talk about their own past experiences.