Correct Answer: C

Rationale: The correct answer is C: Having positive self-esteem. This is unrelated to depression as depression typically involves feelings of worthlessness and low self-esteem. A: Crying and refusing tasks, B: Answering "I forgot to" questions, and D: Neglecting ADLs are all commonly associated symptoms of depression such as apathy, memory issues, and lack of motivation for self-care. Therefore, choice C stands out as the symptom unrelated to depression due to its contradiction with the typical manifestations of the condition.

Correct Answer: B

Rationale: The correct answer is B because it emphasizes the nurse's role in actively working with the patient to address interpersonal problems. The nurse's initial role is to provide support and assistance to the patient in resolving their issues collaboratively. Choice A focuses on medical treatment and collaboration with the doctor, not specifically addressing interpersonal problems. Choice C solely emphasizes the role of medications in improving the patient's well-being, neglecting the interpersonal aspect. Choice D suggests passing off the responsibility to other professionals, which contradicts the nurse's initial role as a source of help for the patient. In summary, choice B is correct because it highlights the nurse's active involvement in solving the patient's interpersonal problems.

Correct Answer: C

Rationale: The correct answer is C: Medications the patient has recently taken. This information is crucial because certain medications can cause symptoms of delirium or exacerbate confusion in elderly patients. By reviewing the patient's recent medications, healthcare providers can identify potential drug-induced causes of confusion and adjust the treatment accordingly. Choice A (Evidence of spasticity or flaccidity) is incorrect because these symptoms are more related to neurological conditions such as stroke or spinal cord injury, not specifically delirium. Choice B (The patient’s level of motor activity) is not as relevant in distinguishing delirium from other problems as medication history, as motor activity can be influenced by various factors. Choice D (Level of preoccupation with somatic symptoms) is also less relevant compared to medication history in differentiating delirium, as somatic symptoms may not always directly indicate the underlying cause of confusion in elderly patients.

Correct Answer: B

Rationale: The correct answer is B because it seeks clarification and prompts the patient to specify who they are referring to when they say "everybody." This response shows active listening and encourages deeper communication. Choice A offers sympathy but doesn't address the issue directly. Choice C dismisses the significance of "frobitzing." Choice D asks for the reason behind "frobitzing" without seeking clarification on the people involved.

Correct Answer: A

Rationale: The correct answer is A: Implement suicide precautions. This is the highest priority because the patient has a plan for suicide, which poses an immediate risk to their safety. Implementing suicide precautions involves ensuring the patient's environment is safe, removing any potential means of self-harm, and closely monitoring the patient to prevent any suicide attempts. Choice B is incorrect because offering high-calorie snacks and fluids frequently addresses the physical aspect of weight loss but does not address the immediate safety concern of suicide. Choice C is incorrect because assisting the patient to identify personal strengths is important for building self-esteem but is not the highest priority when the patient is at risk for suicide. Choice D is incorrect because observing the patient for therapeutic effects of antidepressant medication is important but not as urgent as ensuring the patient's safety in the case of suicidal ideation.