A white patient of German descent rocks back and forth, grimaces, and rubs both temples. What is the nurse's best action?

Correct Answer: D

Rationale: The correct answer is D: Assess the patient for pain. The patient's behavior of rocking back and forth, grimacing, and rubbing temples could indicate pain rather than extrapyramidal symptoms or a need for prayer. Pain assessment is crucial to address the patient's needs effectively. It is essential to rule out pain as a possible cause before considering other interventions. Sitting and rocking with the patient (B) may not address the underlying issue of pain. Offering to pray with the patient (C) may not be appropriate if the patient's primary concern is physical discomfort. Assessing for extrapyramidal symptoms (A) is not the priority in this situation.

Correct Answer: D

Rationale: The correct answer is D: Social isolation R/T inability to relate to others. This is because individuals with schizoid personality disorder often have difficulty forming and maintaining relationships, leading to social isolation. This nursing diagnosis directly addresses the primary issue of the disorder. A: Altered thought processes related to (R/T) increased stress is incorrect because schizoid personality disorder is not typically associated with altered thought processes in the same way as other psychotic disorders. B: Risk for suicide R/T loneliness is incorrect because while individuals with schizoid personality disorder may experience loneliness, it is not necessarily linked to an increased risk for suicide. C: Risk for violence: directed toward others R/T paranoid thinking is incorrect as schizoid personality disorder is not typically characterized by violent behavior or paranoid thinking towards others.

Correct Answer: B

Rationale: The correct answer is B because clients diagnosed with Borderline Personality Disorder (BPD) are more likely to engage in self-destructive behaviors such as self-harm or suicidal ideation, requiring inpatient admission for safety. Clients with antisocial personality disorder (A) typically exhibit behaviors that violate the rights of others, not self-destructive behaviors. Clients with schizoid personality disorder (C) avoid social interactions and are unlikely to engage in self-destructive behaviors. Clients with paranoid personality disorder (D) exhibit distrust and suspiciousness but are not typically associated with self-destructive behaviors.

Correct Answer: A

Rationale: The correct answer is A because individuals with paranoid personality disorder often exhibit distrust, suspicion, and a pervasive pattern of interpreting others' motives as malevolent. They commonly criticize others and have difficulty forming close relationships due to their mistrust. Choice B is incorrect as shyness and fading into the background are not typical characteristics of paranoid personality disorder. Choice C is incorrect as expecting special treatment is more characteristic of narcissistic personality disorder. Choice D is incorrect as being expressive and pleased with oneself are not typical traits of paranoid personality disorder.

Correct Answer: B

Rationale: The correct answer is B because a child with separation anxiety disorder often has a close relationship with a parent who also has an anxiety disorder, leading to increased risk of developing separation anxiety. This is because anxiety disorders can have a genetic component, influencing the child's predisposition to anxiety. Option A is incorrect as antisocial behaviors are not typically associated with separation anxiety disorder. Option C is incorrect because a child's temperament is not directly linked to the development of separation anxiety disorder. Option D is incorrect as inconsistent parenting styles may contribute to other behavioral issues but are not specific to separation anxiety disorder.