Nurse Sheila makes adjustments to the client's plan of care after talking with the client. This is most likely an example of what component of the EBP model?

Correct Answer: B

Rationale: The correct answer is B: client preferences. In the EBP model, client preferences play a crucial role in decision-making. When Nurse Sheila adjusts the client's plan of care after talking with them, she is considering the client's individual needs, values, and preferences. This aligns with the client-centered approach of EBP, where decisions are made collaboratively with the client. Incorrect choices: A: Best available research - While research is important in EBP, in this scenario, the focus is on the client's preferences rather than solely relying on research evidence. C: Nursing expertise - While nursing expertise is valuable, in this case, the emphasis is on incorporating the client's input into the plan of care. D: Review of evidence - While reviewing evidence is a component of EBP, in this scenario, the main focus is on the client's preferences rather than the evidence alone.

Correct Answer: B

Rationale: The correct answer is B because maintaining client confidentiality is a fundamental principle in nursing ethics. By using the client's full name on a submitted record, the student has breached confidentiality. The instructor's priority intervention should be to correct this error and remind the student of the importance of safeguarding client information. Choices A, C, and D are incorrect because they do not address the primary issue of confidentiality breach. Reinforcing accurate documentation (A) is important but secondary to confidentiality. Choice C and D are incorrect as client incompetency or involuntary commitment does not automatically negate the need for confidentiality.

Correct Answer: B

Rationale: The correct answer is B because primary prevention focuses on preventing the development of mental health issues before they occur. Helping school-age children identify and describe normal emotions is an example of primary prevention as it promotes emotional well-being and prevents future mental health problems. Choice A is incorrect because it involves assisting someone who is already diagnosed with a mental illness, which is more of a secondary prevention approach. Choice C involves providing education and support to individuals already in a care home, which falls under secondary prevention. Choice D involves medicating an acutely ill patient, which is more of a tertiary prevention approach aimed at managing existing conditions and preventing further complications.

Correct Answer: C

Rationale: The correct answer is C: incongruous. The patient's verbal statement about the marriage being great contradicts the nonverbal behavior of foot movement and button twirling, indicating incongruity between the verbal and nonverbal communication. This inconsistency suggests that the patient may not be entirely truthful or may be experiencing internal conflict. A: Clear - This choice is incorrect because the patient's communication is not clear due to the conflicting verbal and nonverbal cues. B: Distorted - This choice is incorrect as there is no indication of intentional distortion in the patient's communication. D: Inadequate - This choice is incorrect as inadequate communication refers to a lack of information or detail, which is not evident in this scenario.

Correct Answer: B

Rationale: The correct answer is B: Notify the health care provider to obtain a seclusion order. This is the priority because seclusion should not be continued without a proper order from the health care provider. It ensures legal and ethical compliance, promotes patient safety, and protects the nurse from liability. Completing the physical assessment (A) can wait until after the seclusion order is obtained. Documenting the incident (C) is important but not the immediate priority. Explaining to the patient (D) can be done after ensuring the legal aspects are addressed.