A patient with multi-infarct dementia lashes out and kicks at people who walk past in the hall of a skilled nursing facility. Intervention by the nurse should begin by

Correct Answer: C

Rationale: The correct answer is C because reassuring the patient that the environment is safe can help reduce their feelings of anxiety or fear, which may be causing the aggressive behavior. This approach focuses on creating a calming and supportive atmosphere, which is essential in managing challenging behaviors in dementia patients. A: Gently touching the patient's arm may escalate the situation and provoke a negative response. B: Asking the patient 'What do you need?' may not address the underlying cause of the behavior and could be perceived as confrontational. D: Directing the patient to cease the behavior may be seen as threatening and could lead to further aggression.

Correct Answer: B

Rationale: The correct answer is B because children often express grief through physical symptoms like aches and pains. This is known as somatic complaints. Children may find it difficult to articulate their emotions verbally, so physical symptoms may manifest instead. Option A is incorrect as talking about scary novels is not a common response to grief in children. Option C is incorrect as fear of leaving home is more associated with separation anxiety. Option D is incorrect as becoming obsessed with religious rituals is not a typical response to grief in children.

Correct Answer: B

Rationale: The correct answer is B: Monitor neurological status on an ongoing basis. Delirium is characterized by acute changes in cognition and attention, necessitating continuous monitoring of neurological status to detect any fluctuations or worsening. This allows for prompt intervention and management to prevent complications. A: Assisting with basic needs is important but not specific to delirium management. C: Placing an identification bracelet does not directly address the cognitive changes seen in delirium. D: Giving simple directions is helpful, but monitoring neurological status is more crucial for managing delirium.

Correct Answer: B

Rationale: The correct answer is B because having the client write down information after being directly given the correct information is most effective for clients with schizophrenia. This method helps reinforce learning through repetition and aids memory retention. Writing down information also allows the client to refer back to it for reinforcement. A: Engaging the client in trial and error learning can be frustrating and overwhelming for someone with schizophrenia, leading to confusion. C: Asking the client to guess at the correct answer may increase anxiety and decrease confidence, which can hinder the learning process. D: Using colorful visual aids may be distracting and overwhelming for a client with schizophrenia, making it harder to focus on the information being presented.

Correct Answer: B

Rationale: The correct answer is B because reminding the client's husband of the unit rules is the appropriate nursing response in this situation. This action sets clear boundaries and addresses the inappropriate behavior directly. Asking the client to ask her husband to leave (Option A) puts the burden on the client and may escalate the situation. Asking the husband to come to the nurse's station (Option C) may not address the immediate need to address the abusive behavior. Sitting with the client and her husband to discuss anger issues (Option D) is not appropriate at this time as it does not address the immediate need to stop the verbal abuse.

Correct Answer: D

Rationale: The correct answer is D because impulsivity is a common characteristic of borderline personality disorder and can lead to self-injurious behaviors. The statement "It is almost as if as soon as I think of doing something, I immediately do it" indicates a lack of impulse control and potential for engaging in harmful behaviors without considering consequences. A: This statement expresses feelings of depression but does not directly indicate self-injurious behavior risk. B: This statement suggests a lack of autonomy but does not directly indicate self-injurious behavior risk. C: This statement describes dissociation, which is common in borderline personality disorder but does not directly indicate self-injurious behavior risk. In summary, choice D is the correct answer as it directly implies impulsivity and potential for self-injurious behavior, while the other choices do not clearly indicate this risk.

Correct Answer: C

Rationale: The correct answer is C: Makes himself lunch when he is hungry. This behavior demonstrates adaptation to the new environment as it shows independence and self-care skills. Choosing to prepare a meal when hungry indicates the individual is adjusting to living in the group home by taking care of his basic needs. Options A, B, and D are not necessarily indicative of adaptation to the new environment as they could be influenced by external factors or personal preferences without necessarily reflecting effective adjustment to the group home setting.

Correct Answer: C

Rationale: Correct Answer: C: Risk for Other-Directed Violence related to alcohol withdrawal Rationale: 1. The patient is exhibiting combative behavior and altered thought processes, indicating potential for violent behavior towards others. 2. Other-directed violence encompasses harm towards others, making it a priority to ensure the safety of both the patient and others. 3. This diagnosis addresses the immediate safety concern and allows for interventions to prevent harm to others. Incorrect Choices: A: Risk for Injury - Focuses on self-injury, not directed towards others. B: Risk for Self-Mutilation - Similar to choice A, does not address potential harm towards others. D: Risk for Delayed Development - Not relevant to the current situation of altered thought processes and combative behavior.

Correct Answer: C

Rationale: Step 1: The correct answer is C because it indicates a prolonged period of over 2 months of persistent symptoms such as crying, inability to eat or sleep. Step 2: This prolonged duration of symptoms is indicative of a potential depressive episode. Step 3: The inability to eat or sleep are common symptoms of depression. Step 4: This statement highlights a significant change in the father's behavior following the mother's death, suggesting a possible depressive disorder. Summary: Choice A: The duration of symptoms is not as prolonged as in choice C. Choice B: While agitation and anxiety can be symptoms of depression, they are not as specific or severe as the symptoms in choice C. Choice D: The timeframe of symptoms mentioned here is not as long as in choice C, making it less concerning for depression.