Select the most appropriate label to complete this nursing diagnosis: _____ related to feelings of shyness and poorly developed social skills as evidenced by watching television alone at home every evening.

Correct Answer: C

Rationale: The correct answer is C: Social isolation. This nursing diagnosis best fits the situation described because the individual is experiencing feelings of shyness and poorly developed social skills, leading to isolation by watching television alone every evening. Social isolation refers to a lack of social interactions and connections, which aligns with the symptoms presented. A: Deficient knowledge does not address the social aspect of the situation. B: Ineffective coping does not directly address the social withdrawal behavior. D: Powerlessness does not capture the essence of the individual's situation involving social skills and shyness. In summary, social isolation is the most appropriate label as it directly reflects the individual's behavior and feelings of loneliness and lack of social engagement.

Correct Answer: D

Rationale: The correct answer is D because it directly addresses the ambiguity in the patient's statement by seeking clarification on the term "stoned." This allows the nurse to gain a better understanding of the patient's experience, ensuring effective communication and assessment. Choice A is incorrect as it assumes the patient was uncomfortable with the dream content without confirming it. Choice B relates the nurse's experience, which does not help clarify the patient's statement. Choice C assumes the patient's issue is related to sleep quality, which may not be the case.

Correct Answer: B

Rationale: The correct answer is B because it demonstrates active listening and empathy, inviting the patient to share their perspective. By asking for an example, the nurse acknowledges the patient's feelings and opens up a dialogue for better understanding. Explanation of other choices: A: This choice dismisses the patient's unique experiences and feelings, lacking empathy. C: This choice could come off as minimizing the patient's concerns and not addressing the core issue of feeling misunderstood. D: Changing the subject avoids addressing the patient's feelings and could lead to further disconnect.

Correct Answer: C

Rationale: The correct answer is C: Disturbed body image. This is the priority nursing diagnosis because the patient's statement indicates a distorted perception of their own body, which is a core issue in anorexia nervosa. Addressing the patient's distorted body image is crucial in promoting positive self-perception and working towards recovery. Incorrect choices: A: Imbalanced nutrition: Less than body requirements - While this is a common concern in anorexia nervosa, the patient's statement about needing to lose more weight indicates a deeper psychological issue that needs immediate attention. B: Ineffective coping - While coping strategies are important, the primary focus should be on addressing the distorted body image in this case. D: Risk for injury - While anorexia nervosa can lead to physical complications, the patient's statement does not directly suggest an immediate risk for injury, making this option less of a priority compared to addressing the distorted body image.

Correct Answer: A

Rationale: The correct answer is A because the priority in this situation is to ensure the patient's safety. By ensuring the patient is in a safe environment and assessing for suicidal thoughts and behaviors, the nurse can prevent harm to the patient. Encouraging reality-based activities (B) and providing reassurance (C) may not address the immediate risk of harm posed by the voices. Asking about the content of the voices and validating their experiences (D) may be important for understanding the patient's perspective, but safety should come first.