Assessment of a client with schizophrenia reveals that he is hearing voices that tell him that people are staring at him and illusions. When developing the plan of care for this client, which nursing diagnosis would be most appropriate?

Correct Answer: C

Rationale: The most appropriate nursing diagnosis for a client with schizophrenia experiencing auditory hallucinations and illusions is "Disturbed sensory perception" (C). This diagnosis reflects the client's altered sensory experiences, such as hearing voices and experiencing illusions. It focuses on the client's perception of reality, which is impaired in this case. Choice A (Disturbed thought processes) is incorrect because it primarily focuses on cognitive processes rather than sensory experiences. Choice B (Risk for self-directed violence) is not the most appropriate because the client's symptoms do not directly indicate a risk of self-harm. Choice D (Ineffective coping) is also not as relevant in this case as the primary issue is related to sensory perception rather than coping mechanisms. Therefore, the correct diagnosis is "Disturbed sensory perception" as it addresses the client's altered sensory experiences.

Correct Answer: C

Rationale: The correct answer is C because during the first interview with a patient with a psychiatric disorder, it is crucial for the nurse to address relationship parameters to establish a therapeutic alliance, discuss the contract to clarify roles and expectations, ensure confidentiality to build trust, and explain termination to manage expectations. These aspects lay the foundation for a successful therapeutic relationship. A: Trust, congruence, attitudes, and boundaries - While trust and boundaries are important, they are part of relationship parameters addressed in choice C. Congruence and attitudes are more about the nurse's behavior than issues to address with the patient initially. B: Goals, resistance, unconscious motivations, and diversion - These are important aspects, but they are more relevant in later stages of therapy after a strong therapeutic alliance has been established. D: Transference, countertransference, intimacy, and developing resources - These are advanced concepts that may be addressed later in therapy as trust and rapport are established.

Correct Answer: C

Rationale: The correct answer is C because validation therapy involves acknowledging and validating the person's feelings and reality. By reiterating the patient's desire to go home and prepare dinner for her husband, the nurse validates the patient's emotions and reality, which can help reduce distress and agitation. Choice A is incorrect because it simply redirects the patient without acknowledging her feelings or reality. Choice B is incorrect because it focuses on the patient's widow status rather than validating her current feelings and beliefs. Choice D is incorrect because it introduces a potentially negative and untrue statement about the patient's husband, which could escalate the situation rather than providing validation.

Correct Answer: C

Rationale: The most appropriate nursing diagnosis for a client with schizophrenia experiencing auditory hallucinations and illusions is "Disturbed sensory perception" (C). This diagnosis reflects the client's altered sensory experiences, such as hearing voices and experiencing illusions. It focuses on the client's perception of reality, which is impaired in this case. Choice A (Disturbed thought processes) is incorrect because it primarily focuses on cognitive processes rather than sensory experiences. Choice B (Risk for self-directed violence) is not the most appropriate because the client's symptoms do not directly indicate a risk of self-harm. Choice D (Ineffective coping) is also not as relevant in this case as the primary issue is related to sensory perception rather than coping mechanisms. Therefore, the correct diagnosis is "Disturbed sensory perception" as it addresses the client's altered sensory experiences.

Correct Answer: B

Rationale: The correct answer is B: Evaluation of the family's ability to effectively care for the older client. Rationale: 1. Evaluating the family's ability to care for the older client is crucial as it helps in assessing the overall support system available to the client. 2. Family members' involvement can provide insights into the client's daily care needs, potential challenges, and resources available for caregiving. 3. Understanding the family dynamics and capabilities helps the nurse in developing a comprehensive care plan that considers both the client's needs and the family's capacity to provide care. 4. This choice directly relates to the importance of involving family members in mental health assessment of older adults, highlighting the significance of assessing the caregiving abilities within the family unit. Summary: - A: While interviewing family members may provide information about social support resources, this is not the primary focus when evaluating the family's caregiving abilities. - C: Determining the extent of memory impairment is important but not the primary purpose of involving family