The care for the client places priority on which of the following:

Correct Answer: D

Rationale: The correct answer is D: Administering Librium as ordered. This is the priority because Librium is a medication prescribed for specific therapeutic reasons, such as managing withdrawal symptoms or anxiety. Administering it as ordered ensures the client's safety and well-being. Monitoring vital signs (A) is important but not the priority over administering necessary medication. Providing a quiet, dim room (B) and encouraging fluids and nutrition (C) are important for comfort and health but do not address immediate medical needs like medication administration.

Correct Answer: A

Rationale: The correct answer is A: Avoid taking CNS depressants like alcohol. Valium is a central nervous system (CNS) depressant, so combining it with other CNS depressants like alcohol can lead to dangerous levels of sedation, respiratory depression, and even overdose. It is crucial to educate clients to avoid alcohol while taking Valium to prevent these serious complications. Explanation for incorrect choices: B: There are no restrictions in activities - This is incorrect because clients taking Valium should be advised to avoid activities that require mental alertness or coordination due to the sedative effects of the medication. C: Limit fluid intake - This is incorrect as there is no specific need to limit fluid intake while taking Valium unless advised by a healthcare provider for other medical reasons. D: Any beverage like coffee may be taken - This is incorrect as caffeine in beverages like coffee can potentially interact with Valium and affect its effectiveness, so it is important to provide guidance on caffeine intake while on Valium.

Correct Answer: A

Rationale: The correct answer is A: Education and work history. The nurse would identify this as least significant in contributing to the client's sexual difficulty because education and work history do not directly impact sexual arousal or fear of infidelity in a marriage. Rationale: 1. B: Medication used - Medications can have side effects that affect sexual arousal and libido. 2. C: Physical health status - Physical health can impact sexual function and overall well-being. 3. D: Quality of spousal relationship - Relationship dynamics can significantly influence sexual arousal and fear of infidelity. In summary, the client's education and work history are less likely to directly affect her sexual difficulties compared to medication, physical health, and the quality of her spousal relationship.

Correct Answer: D

Rationale: The priority nursing diagnosis for a client with bipolar disorder, manic type, exhibiting extreme excitement, delusional thinking, and command hallucinations is "D: Risk for other-directed violence." This is the most critical because it addresses the immediate safety concern of potential harm to others due to the client's altered mental state. Anxiety (A) may be present but is secondary to the risk of violence. Impaired social interaction (B) and disturbed sensory-perceptual alteration (C) are important but not as urgent as ensuring the safety of others. It is crucial to prioritize interventions to prevent harm to others in this scenario.

Correct Answer: C

Rationale: Rationale: C is correct because assessing the client's perception of the triggering event helps understand their crisis context, and evaluating situational supports is crucial for intervention planning. A is not as essential because coping skills can vary. B focuses on emotions but may not address the root cause. D is important but not as critical as understanding the triggering event and available supports.