Correct Answer: B

Rationale: Ativan and lorazepam are the same drug, so the patient is taking an excessive dose of lorazepam. This requires intervention by the nurse to prevent harm.

Correct Answer: C

Rationale: Self-harm in response to hallucinations reflects impaired ability to control impulses and respond safely to internal stimuli.

Correct Answer: A

Rationale: Boundaries define responsibilities and duties to one’s self in relation to others. Setting boundaries is essential in establishing a safe and professional therapeutic relationship between a nurse and a patient. These boundaries help to create a clear understanding of each person's roles and responsibilities within the relationship. Boundaries also help protect both the nurse and the patient from potential harm, maintain professionalism, and ensure effective communication and focus on the therapeutic goals. By defining these boundaries, the nurse can better maintain appropriate relationships with patients and avoid conflicts of interest or ethical dilemmas.

Correct Answer: C

Rationale: The nurse's role in music therapy is to note patient verbal and nonverbal expression of feelings. In music therapy, the focus is on using music as a tool to help patients express themselves, connect with their emotions, and communicate their feelings in a non-verbal manner. The nurse's job is to observe and interpret how the patients are engaging with the music and using it as a medium to express their inner thoughts and emotions. This can help in promoting emotional well-being and providing a space for patients to process their feelings in a therapeutic way.

Correct Answer: A

Rationale: The wife's statement, "It can't be," indicates that she is experiencing shock and disbelief at the news of her husband's death. This response is common when individuals are faced with a sudden and unexpected loss. The wife's blank stare and statement suggest that she is struggling to accept the reality of the situation, which aligns with the symptoms of shock and disbelief.