Prior to administering chlorpromazine (Thorazine) to an agitated client, the nurse should:

Correct Answer: C

Rationale: The correct answer is C: Take the client's blood pressure. Before administering chlorpromazine, it is important to assess the client's blood pressure as the medication can cause hypotension as a side effect. Monitoring blood pressure helps to ensure the client's safety and prevents potential complications. Assessing skin color and sclera (A) may be important for other assessments but not specifically related to chlorpromazine administration. Assessing the radial pulse (B) is important for monitoring cardiovascular status but may not be directly impacted by chlorpromazine. Asking the client to void (D) is not directly related to assessing for potential side effects of chlorpromazine.

Correct Answer: B

Rationale: The correct answer is B: Development of autonomy within the family. Differentiation in family systems theory refers to the ability of individuals to maintain their own sense of self while being emotionally connected to family members. This process involves developing autonomy, where family members can express their own thoughts, feelings, and values independently. This is crucial for healthy family dynamics and individual growth. Incorrect Options: A: Cooperative action among members of the family - While cooperation is important in family systems, it does not specifically refer to the process of differentiation. C: Incongruent messages wherein the recipient is a victim - This option describes communication issues rather than differentiation. D: Maintenance of system continuity or equilibrium - This option refers to the overall stability of the family system, which is different from the process of differentiation.

Correct Answer: A

Rationale: The correct answer is A because it dismisses the client's feelings and concerns by invalidating them with a generic reassurance. It fails to acknowledge the client's emotions and can come across as patronizing. Choice B acknowledges the client's emotional state, while choice C observes a behavior without judgment. Choice D addresses the client's thoughts without dismissing them, making it a more empathetic response.

Correct Answer: A

Rationale: Step-by-step rationale: 1. The nurse holds a Western worldview, which may not align with the cultural beliefs of Hispanic patients. 2. Using pamphlets may not effectively communicate information in a culturally sensitive manner. 3. Short and concise groups may be perceived as rushed or lacking in depth. 4. Patients may feel the nurse was uncaring due to the mismatch in cultural understanding and communication style. Summary: The correct answer is A because cultural differences and communication styles can lead to patients feeling uncared for despite the nurse's intentions. Choices B, C, and D are incorrect because effectiveness, efficiency, and respect can be compromised when cultural considerations are not adequately addressed.

Correct Answer: B

Rationale: The correct answer is B: Chronic low self-esteem. This diagnosis is appropriate because the patient's statement reflects a long-standing negative self-view, which aligns with chronic low self-esteem. The patient's feelings of inadequacy and self-doubt are indicative of this diagnosis. Choice A (Risk for other-directed violence) is incorrect because there is no evidence or indication of potential for violence in the patient's statement. Choice C (Deficient knowledge) is incorrect as the patient's concerns are related to self-perception rather than a lack of knowledge. Choice D (Social isolation) is incorrect because although the patient mentions feeling isolated in the past, the primary issue in the statement is low self-esteem rather than social isolation.