On a substance abuse unit, a client diagnosed with cirrhosis of the liver tells the nurse,"I really don't believe that drinking a couple of cocktails every night has anything to do with my liver problems." Which is the best nursing response?

Correct Answer: A

Rationale: The correct answer is A. This response uses therapeutic communication by reflecting the client's statement back to them. By doing so, the nurse acknowledges the client's perspective without being confrontational. It opens the door for further discussion and exploration of the client's beliefs around alcohol and liver damage. This approach helps build rapport and trust with the client, allowing for a more effective therapeutic relationship. Choices B, C, and D are incorrect because they do not address the client's denial or beliefs directly. Choice B focuses on gathering more information about the client's drinking habits without addressing the client's statement. Choice C asks for an explanation without validating the client's feelings. Choice D is a general statement that may come across as judgmental and does not address the client's specific belief.

Correct Answer: B

Rationale: The correct answer is B because it follows the SOAP (Subjective, Objective, Assessment, Plan) format for problem-oriented charting. In choice B, the subjective information is the patient's statement, the objective information includes the observed behavior, assessment is the diagnosis of auditory hallucinations, and the plan includes offering medication and the outcome. Choice A lacks a clear assessment and plan, focusing more on the intervention and outcome. Choice C does not clearly link the assessment to the plan and lacks details in the subjective and objective sections. Choice D does not provide a clear separation between subjective and objective information and lacks a formal assessment section.

Correct Answer: C

Rationale: The correct answer is C: Projection. This defense mechanism involves attributing one's own unacceptable feelings or traits to others. In this scenario, the nurse is projecting her disappointment onto the nurse manager by suggesting that the manager's headache influenced the decision. This allows the nurse to avoid taking responsibility for not getting the promotion. A: Introjection involves internalizing external beliefs or values, which is not evident in this scenario. B: Conversion involves converting psychological distress into physical symptoms, which is not relevant to the situation. D: Splitting involves viewing people as all good or all bad, which is not demonstrated in this case.

Correct Answer: C

Rationale: The correct answer is C because an alteration in mood or thinking is a key characteristic of mental disorders. This indicates a disruption in normal cognitive or emotional processes, which is a defining feature of mental illnesses. Choices A, B, and D are incorrect because they do not specifically address the core symptoms of mental disorders. Capacity to interact with others (A) and ability to deal with stress (B) are important aspects of mental health but do not necessarily indicate the presence of a mental disorder. Lack of impaired functioning (D) does not capture the complexity of mental disorders, as individuals can still experience mental health issues even if they are able to function in certain areas of their life.

Correct Answer: A

Rationale: The correct answer is A because in a nontherapeutic relationship, the first step would be the nurse failing to recognize the patient as a person with a need. This sets the foundation for the relationship to be unhelpful and potentially harmful. B, C, and D are incorrect as they are consequences or outcomes of a nontherapeutic relationship, not the initial cause. The nurse-patient relationship starts with the nurse acknowledging the patient's needs to establish trust and promote therapeutic communication.