The initial response by the nurse to a delusional client who refuses to eat because of a belief that the food is poisoned is

Correct Answer: A

Rationale: Reflecting the delusion encourages discussion without confrontation.

Correct Answer: C

Rationale: A warm compress increases blood flow and relaxes sore muscles by dilating blood vessels, delivering oxygen and nutrients to the area, and easing tension. This promotes healing and reduces stiffness, common in patients with muscle soreness from immobility or injury. Inducing sleep might be a byproduct of relaxation, but it's not the primary aim. Cooling the area requires a cold compress, not warm, and is used for different purposes like reducing swelling. Minimizing repositioning isn't relevant warmth targets muscle relief, not positioning needs. Nurses apply this intervention to enhance comfort and support recovery, leveraging heat's physiological benefits effectively.

Correct Answer: A

Rationale: Standing on the side opposite the patient's weaker leg when assisting with a cane provides optimal support, as the cane is typically held on the stronger side to bear weight, while the nurse stabilizes the weaker side. Standing opposite the stronger leg reduces assistance where it's most needed. Any side ignores biomechanics, risking imbalance. Directly in front obstructs the path and hinders movement. This positioning leverages the cane's role as a weight-bearing aid, ensuring safety and confidence during ambulation, a critical nursing consideration for mobility-impaired patients.

Correct Answer: C

Rationale: Applying elastic stockings in the morning ensures they're put on before dependent edema worsens from gravity, maximizing their role in promoting venous return and preventing clots. Rolling them down to the ankles negates their purpose full leg coverage is key. Tightness matters, but fit must be correct, not excessive, to avoid constriction. Loose stockings fail to compress adequately, reducing effectiveness. Nurses time this intervention when swelling is minimal, aligning with circulatory needs and enhancing patient comfort and safety throughout the day.

Correct Answer: C

Rationale: A footboard maintains proper alignment of the legs and feet by preventing foot drop where toes point downward from prolonged bed rest preserving dorsiflexion and reducing contracture risk. Comfort might improve indirectly, but alignment is the goal. Restricting movement isn't accurate it prevents deformity, not mobility itself. Decoration is irrelevant; it's functional. Nurses position it to support the soles, countering gravity's pull on immobile patients, ensuring long-term musculoskeletal health and aiding future ambulation.