An 85-year-old client has become agitated and physically aggressive after having a stroke with right-sided weakness. The client is started on risperidone PO 0.5 mg qhs. Which is a priority nursing diagnosis for this client?

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: A

Rationale: The correct answer is A because it promotes cognitive-behavioral techniques to manage anger effectively. By helping the patient identify triggering thoughts, evaluate their validity, and replace them with reality-based thinking, nurses can assist in changing the patient's response to anger. This intervention encourages self-awareness and empowers the patient to develop healthier coping mechanisms. Choice B is incorrect as it promotes punitive measures, which can escalate aggression and undermine trust between the patient and healthcare provider. Choice C is incorrect as aversive conditioning methods like popping a rubber band on the wrist are not evidence-based and can be harmful. Choice D is incorrect as medication should not be the first-line intervention for managing anger without violence.

Correct Answer: C

Rationale: The correct answer is C: Family development. The Calgary Family Model focuses on understanding how families develop and change over time. It emphasizes the importance of recognizing different stages of family development, such as forming, norming, storming, and performing. By understanding these stages, nurses can provide more effective care tailored to the family's specific needs. A: Differentiation of self is a concept from Bowen's Family Systems Theory, not the Calgary Family Model. B: Sibling position is a concept from Adlerian Family Therapy, not the Calgary Family Model. D: Subsystems refer to the different components within a family system, but it is not the primary focus of the Calgary Family Model, which is on family development.

Correct Answer: A

Rationale: The correct answer is A: referring the client for hypnosis. Hypnosis is an evidence-based nonpharmacologic intervention for chronic pain that can help manage pain perception and improve coping mechanisms. It is safe and effective for long-term pain management. Referring for hypnosis aligns with the holistic approach to chronic pain management. Choice B: administering pain medication as prescribed is a pharmacologic intervention, not nonpharmacologic. Choice C: removing all glaring lights and excessive noise can help create a comfortable environment but may not directly address chronic pain relief. Choice D: using over-the-counter transcutaneous electric nerve stimulation is a nonpharmacologic intervention, but it may not be as effective for chronic pain as hypnosis.

Correct Answer: B

Rationale: The correct answer is B because the female reporting still hearing her daughter's pleas for help is exhibiting symptoms characteristic of acute stress reaction, a common response to traumatic events like a major fire. This symptom indicates a re-experiencing of the traumatic event, known as intrusion, which is a key feature of acute stress reactions. This can include vivid memories, flashbacks, or hearing sounds related to the traumatic event. Choices A, C, and D do not align with acute stress reactions. A male with mood swings between mania and depression (Choice A) is more likely experiencing bipolar disorder. A male repeating 'I don't understand what's going on?' (Choice C) may indicate confusion or disorientation rather than acute stress reaction. A female rocking her young son and repeating 'it will be okay' (Choice D) may be demonstrating a coping mechanism rather than a symptom of acute stress reaction.