Correct Answer: C

Rationale: (C) is the best response as it redirects the client to a safer, familiar place. (A) is dismissive and does not address the client's needs directly. (B) labels the behavior, which may increase the client's anxiety. (D) is scolding and may not be helpful in the situation.

Correct Answer: A

Rationale: The correct action for the nurse to implement is to administer acetylcysteine (Mucomyst). Acetylcysteine is the antidote for acetaminophen overdose and should be administered promptly to prevent liver damage. Monitoring cardiac rhythm for flat T waves (Choice B) is not specific to acetaminophen overdose and is more related to cardiac conditions. Checking serum AST and ALT levels (Choice C) may be done later but is not the initial priority in this situation. Similarly, preparing to administer Syrup of Ipecac (Choice D) is not recommended anymore in cases of overdose as it can cause more harm.

Correct Answer: B

Rationale: Using open-ended questions and focusing on the client's self-disclosure about food preferences can help build rapport and trust with the client, encouraging them to eat. Identifying the reasons the client has for not wanting to eat can provide insights into their concerns. However, offering opinions about the necessity for adequate nutrition may come across as imposing views on the client, potentially leading to resistance. This approach may not be as effective in encouraging the client to eat as it could create a power dynamic that hinders the therapeutic relationship.

Correct Answer: B

Rationale: The correct answer is to tell the client that the nurse is there and will help her. Providing reassurance and presence is more therapeutic in dealing with a client who has advanced dementia and is expressing a desire to go home and be with her mother. Option A might not be effective as continuously orienting the client may not alleviate her distress. Option C, reminding the client that her mother is no longer living, can be distressing and may not be appropriate in this situation. Option D, explaining the seriousness of the injury and need for hospitalization, is not the best response as it does not address the client's emotional needs at that moment.

Correct Answer: C

Rationale: Psychotic clients often experience delusions due to difficulties with trust and low self-esteem (C). In this case, the client's belief that someone is trying to poison him is likely a manifestation of his underlying issues with trust and self-worth. Building trust and promoting positive self-esteem are essential in caring for such clients. Choices A, B, and D are incorrect because delusions are not primarily related to early childhood experiences involving authority issues, anger about hospitalization, or phobic fear of food. These factors do not directly contribute to the development of delusions in psychotic clients.