Situation: In a home visit done by the nurse, she suspects that the wife and her child are victims of abuse. Which of the following is the most appropriate for the nurse to ask?

Correct Answer: A

Rationale: The correct answer is A because it directly addresses the issue of abuse by asking if the wife and child are being threatened or hurt by the partner. This question is clear, specific, and focuses on the potential abuse situation. It allows the nurse to gather crucial information to assess the safety of the family. Choice B is not as effective because it only asks if the wife is frightened, which may not necessarily reveal if abuse is present. Choice C is too vague and open-ended, not directly addressing the suspected abuse. Choice D focuses on arguments, which may not uncover the extent of abuse occurring in the household. Therefore, A is the most appropriate question in this situation.

Correct Answer: D

Rationale: The correct answer is D because rearranging the environment to activate the child is not a recommended therapeutic approach for caring for an autistic child. Autistic children may struggle with changes in their environment, so rearranging it could lead to increased stress and anxiety, rather than therapeutic benefits. A: Engaging in diversionary activities when acting-out can help redirect behavior and provide a positive outlet for emotions. B: Providing an atmosphere of acceptance fosters a sense of security and belonging for the child. C: Providing safety measures is crucial to ensure the well-being of the child and prevent any harm. In summary, D is incorrect as it could potentially disrupt the child's sense of stability, while A, B, and C are all important aspects of the therapeutic approach in caring for an autistic child.

Correct Answer: C

Rationale: The correct answer is C: Remains in a safe and secure environment. This is the primary nursing intervention because clients with moderate stage dementia may have impaired judgment and memory, making them vulnerable to accidents or wandering. Keeping them in a safe and secure environment helps prevent injuries or getting lost. Choice A is important but not the primary intervention as safety comes first. Choice B, reminiscing, is beneficial for cognitive stimulation but not a priority for safety. Choice D, self-care, may be challenging for clients with dementia, so ensuring safety takes precedence.

Correct Answer: C

Rationale: The correct answer is C: Claustrophobia. Claustrophobia is an intense fear of confined spaces, such as elevators. In this case, the individual's fear of riding an elevator and the belief of dying inside indicate a fear of being trapped in a small space, which aligns with the symptoms of claustrophobia. Agoraphobia (A) is a fear of open or public spaces, social phobia (B) is a fear of social situations, and xenophobia (D) is a fear of strangers or foreigners, none of which match the symptoms described in the scenario.

Correct Answer: D

Rationale: The correct answer is D: Use the services of an interpreter. This is the best nursing intervention because it ensures accurate communication and understanding between the nurse and the psychiatric client who speaks a foreign language. Using an interpreter helps convey complex and nuanced information effectively, promotes trust and rapport, and ensures the client's needs are accurately addressed. Rationale for why the other choices are incorrect: A: Relying on nonverbal communication may lead to misunderstandings and misinterpretations, especially in a psychiatric setting where verbal communication is crucial. B: Selecting symbolic pictures as aids may be helpful to some extent, but it may not fully address the client's communication needs and may limit the depth of conversation. C: Speaking in universal phrases may be too simplistic and may not capture the complexity of the client's thoughts and emotions when addressing mental health issues.