An adolescent asks a nurse conducting an assessment interview, 'Why should I tell you anything? You'll just tell my parents whatever you find out.' Which response by the nurse is appropriate?

Correct Answer: C

Rationale: The correct answer is C because it acknowledges the importance of confidentiality regarding the adolescent's feelings while also highlighting the necessity of reporting certain critical issues like suicidal thoughts to ensure the adolescent's safety. This response respects the adolescent's privacy while prioritizing their well-being. Choice A is incorrect because it inaccurately states that everything is held in strict confidence, which may not be the case for issues like suicidal thoughts. Choice B is incorrect as it dismisses the adolescent's concerns about privacy and may deter them from being open during the assessment. Choice D is incorrect as it makes assumptions about the adolescent's readiness without addressing their specific concerns about confidentiality.

Correct Answer: C

Rationale: The correct answer is C: Social isolation. This nursing diagnosis best fits the situation described because the individual is experiencing feelings of shyness and poorly developed social skills, leading to isolation by watching television alone every evening. Social isolation refers to a lack of social interactions and connections, which aligns with the symptoms presented. A: Deficient knowledge does not address the social aspect of the situation. B: Ineffective coping does not directly address the social withdrawal behavior. D: Powerlessness does not capture the essence of the individual's situation involving social skills and shyness. In summary, social isolation is the most appropriate label as it directly reflects the individual's behavior and feelings of loneliness and lack of social engagement.

Correct Answer: A

Rationale: The correct answer is A because it acknowledges the patient's thoughtfulness and the positive relationship between the nurse and patient. Accepting the card shows appreciation and fosters a sense of connection and trust. It also validates the patient's effort in making the card. Choice B is incorrect because it focuses solely on facility policies and may come off as cold and uncaring, potentially damaging the nurse-patient relationship. Choice C is incorrect because declining the card without acknowledging the patient's effort and the positive relationship may leave the patient feeling unappreciated. Choice D is incorrect as it assumes the patient wants to return for other activities when the situation is about expressing gratitude for the current experience.

Correct Answer: D

Rationale: The correct answer is D because it directly addresses the ambiguity in the patient's statement by seeking clarification on the term "stoned." This allows the nurse to gain a better understanding of the patient's experience, ensuring effective communication and assessment. Choice A is incorrect as it assumes the patient was uncomfortable with the dream content without confirming it. Choice B relates the nurse's experience, which does not help clarify the patient's statement. Choice C assumes the patient's issue is related to sleep quality, which may not be the case.

Correct Answer: B

Rationale: The correct answer is B because it demonstrates active listening and empathy, inviting the patient to share their perspective. By asking for an example, the nurse acknowledges the patient's feelings and opens up a dialogue for better understanding. Explanation of other choices: A: This choice dismisses the patient's unique experiences and feelings, lacking empathy. C: This choice could come off as minimizing the patient's concerns and not addressing the core issue of feeling misunderstood. D: Changing the subject avoids addressing the patient's feelings and could lead to further disconnect.