The desired outcome for a patient experiencing insomnia is, "Patient will sleep for a minimum of 5 hours nightly within 7 days." At the end of 7 days, review of sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. The nurse will document the outcome as:

Correct Answer: C

Rationale: The correct answer is C: Sometimes demonstrated. The rationale is that the patient is not consistently meeting the desired outcome of sleeping for a minimum of 5 hours nightly within 7 days. Although the patient is sleeping for an average of 4 hours nightly, the 2-hour afternoon nap indicates that the patient is not achieving the desired outcome consistently. Therefore, the nurse would document the outcome as "Sometimes demonstrated" to reflect that the patient is making progress towards the goal but has not fully achieved it. Choices A, B, and D are incorrect because the patient's sleep behavior does not align with being consistently, often, or never demonstrated based on the desired outcome criteria.

Correct Answer: A

Rationale: The correct answer is A because involving the entire family in therapy sessions allows for a more comprehensive understanding of the family dynamics and how they may be contributing to the child's issues. By including all family members, the nurse can gather diverse perspectives and insights that can inform the treatment plan. This approach also promotes family unity and collaboration in addressing the child's problems. Option B is not the best response as it lacks a clear rationale for involving the whole family. Option C, while partially true, does not directly address the question raised by the mother. Option D emphasizes the importance of every family member's perceptions but does not specifically address the benefits of involving the entire family in therapy sessions.

Correct Answer: B

Rationale: The correct answer is B because limiting exposure to violence on TV, video, and computer games falls under primary prevention by addressing risk factors before violent behaviors occur. This intervention helps reduce the likelihood of children and adolescents developing violent tendencies by minimizing their exposure to violent content that can influence their behavior. A: Forbidding the child to continue friendships with violent peers is more of a secondary prevention strategy targeting existing risk factors, not primary prevention. C: Seeking counseling for a child who has been experimenting with drugs is also a secondary prevention strategy focusing on addressing a specific risk factor, not primary prevention. D: Showing a unified approach to parenting when dealing with a violent child is a tertiary prevention strategy aimed at managing and reducing harm after the behavior has already occurred, not primary prevention.

Correct Answer: A,C

Rationale: The correct answers are A and C. A nurse should evaluate if the older patient can prepare nutritious meals independently, as this indicates their ability to meet basic nutritional needs and maintain independence in daily living. Additionally, assessing if the patient can perform regular, simple maintenance on their primary residence is important for gauging their ability to live safely and comfortably. Choices B and D are incorrect as financial resources and toileting abilities, while important, do not directly reflect functional status in the same way as meal preparation and home maintenance.

Correct Answer: D

Rationale: The correct answer is D because it provides an empathetic response by acknowledging the concern of the parent and demonstrating an understanding of the genetic link between twins and schizophrenia. By citing a specific statistic (50%), it shows knowledge of the relationship between genetics and the development of schizophrenia in twins. Choice A is incorrect because it downplays the genetic influence by suggesting a small chance, which is not accurate. Choice B is incorrect because it dismisses the seriousness of the situation and does not address the genetics aspect of the disorder. Choice C is incorrect because it is not based on factual information and offers sympathy without addressing the genetic component of schizophrenia in twins.

Correct Answer: C

Rationale: The correct answer is C. It acknowledges the client's autonomy while also addressing their concerns. First, it recognizes the client's right to discontinue treatment. Second, it opens the door for a discussion to explore the client's worries and provide support. This response shows empathy and respects the client's decision-making. Choice A is incorrect because it dismisses the client's autonomy and fails to address their concerns. Choice B is not as appropriate as it suggests only talking to the doctor, missing the opportunity for the nurse to provide immediate support. Choice D is incorrect as it invalidates the client's experience of memory loss and fails to address their concerns.

Correct Answer: A

Rationale: The correct answer is A: The "here and now." In a task group, the focus is on addressing specific goals, tasks, and problem-solving in the present moment. This approach helps members work together efficiently to achieve objectives. Communication styles (B) are more relevant in a group focused on improving communication skills. Relations among the members (C) are typically emphasized in a process group, where the focus is on interpersonal dynamics and relationships. Choice D is incomplete and does not align with the purpose of a task group.

Correct Answer: C

Rationale: The correct answer is C: Sometimes demonstrated. The rationale is that the patient is not consistently meeting the desired outcome of sleeping for a minimum of 5 hours nightly within 7 days. Although the patient is sleeping for an average of 4 hours nightly, the 2-hour afternoon nap indicates that the patient is not achieving the desired outcome consistently. Therefore, the nurse would document the outcome as "Sometimes demonstrated" to reflect that the patient is making progress towards the goal but has not fully achieved it. Choices A, B, and D are incorrect because the patient's sleep behavior does not align with being consistently, often, or never demonstrated based on the desired outcome criteria.

Correct Answer: B

Rationale: The correct answer is B because acute grief typically involves conflicting and unresolved emotions and thoughts related to the loss. The nurse would assess for unresolved issues to provide appropriate support and interventions. Choice A is incorrect as severe depressive symptoms may indicate complicated grief, not typical acute grief. Choice C is incorrect as increased arousal and hypervigilance are more characteristic of post-traumatic stress disorder. Choice D is incorrect as preoccupation with the image of the deceased may be a common experience in grief but does not encompass the full range of emotions and conflicts that acute grief entails.