During the acute phase of a burn, the priority nursing intervention in caring for this client is:

Correct Answer: D

Rationale: During the acute phase of a burn, fluid resuscitation is the priority nursing intervention. This phase is characterized by fluid loss and the risk of hypovolemic shock. Administering fluids is crucial to maintain perfusion and prevent complications such as organ failure. While prevention of infection, pain management, and prevention of bleeding are important aspects of burn care, fluid resuscitation takes precedence in the acute phase to stabilize the client's condition and prevent further damage.

Correct Answer: A

Rationale: In a Nurse-Patient interaction, the most important quality of a nurse is understanding (Option A). Understanding encompasses empathy, compassion, and the ability to truly comprehend the patient's needs, concerns, and feelings. This quality forms the foundation of effective communication, trust-building, and holistic care delivery. When a nurse demonstrates understanding, it fosters a therapeutic relationship, enhances patient outcomes, and promotes patient-centered care. Listening (Option C) is crucial in nursing practice, but understanding goes beyond just hearing words; it involves interpreting and empathizing with the patient's perspective. Acceptance (Option B) is important, but without understanding, it may lack depth and authenticity. Teaching (Option D) is valuable but comes after establishing understanding and rapport with the patient. Educationally, emphasizing the importance of understanding in nurse-patient interactions helps students develop essential interpersonal skills, empathy, and communication techniques. By prioritizing understanding, nurses can deliver more effective and compassionate care, ultimately improving patient experiences and outcomes.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Delusion. A delusion is a fixed, false belief that is not based in reality. In this case, Mang David's belief that he is the top salesman in the world and that different companies want him is a clear example of a delusion commonly seen in individuals with schizophrenia. Option A) Hallucination refers to sensory perceptions that are not based in reality, such as hearing voices or seeing things that are not there. In this case, Mang David's statement does not involve a sensory perception, so it is not a hallucination. Option C) Confabulation is the creation of false memories or stories without the intention to deceive. Mang David's statement is not a fabrication or false memory but rather a fixed false belief, making this option incorrect. Option D) Flight of Ideas is a rapid shifting from one idea to another, often associated with manic episodes in conditions like bipolar disorder. Mang David's statement does not demonstrate this symptom, making this option incorrect in this context. Educationally, understanding the difference between hallucinations, delusions, confabulations, and flight of ideas is crucial for healthcare professionals working with psychiatric clients. Recognizing and correctly interpreting these symptoms can aid in providing appropriate care and interventions for individuals with mental health disorders like schizophrenia.

Correct Answer: C

Rationale: The correct answer is C) Simply state that the food is not poisoned. This intervention is the best approach when dealing with a paranoid client who refuses to eat due to the belief that the food is poisoned. By calmly and confidently stating that the food is safe, the nurse acknowledges the client's concerns while providing reassurance and factual information. This response helps build trust and rapport with the client, which is essential in managing paranoia and promoting a therapeutic relationship. Option A) - Taste the food in front of him and tell him that the food is not poisoned, may not be appropriate as it could reinforce the client's delusion or paranoia. It is essential to address the client's concerns without engaging in behaviors that could validate their irrational beliefs. Option B) - Offer other types of food until the client eats, does not directly address the client's paranoia and may not effectively resolve the issue at hand. It is crucial to focus on addressing the client's specific concern rather than avoiding it. Option D) - Offer sealed foods, while a good practice in general for food safety, may not adequately address the client's underlying paranoia. The focus should be on communication and therapeutic relationship building rather than solely changing the method of food delivery. In a clinical setting, understanding how to communicate effectively with clients experiencing paranoia is crucial. Nurses must approach such situations with empathy, respect, and a non-judgmental attitude. By providing clear and concise information, nurses can help clients feel supported and understood, ultimately improving their overall care and well-being.

Correct Answer: C

Rationale: Elizabeth Kubler-Ross identified five stages of grief: denial, anger, bargaining, depression, and acceptance. The correct answer is option D. Denial was not included in option C, making it incorrect. Option A is incorrect as it does not include bargaining, one of the key stages in Kubler-Ross's model. Option B is incorrect because it lists identification instead of bargaining. In an educational context, understanding the stages of grief is crucial for healthcare professionals, including nurses. Knowing these stages can help nurses provide better care for patients and families experiencing grief and loss. By recognizing and understanding these stages, nurses can offer appropriate support, empathy, and interventions tailored to the individual's needs during the grieving process. This knowledge is essential in various healthcare settings, as nurses often encounter patients and families dealing with loss and grief.