The mental health nurse observes that a female client with delusional disorder carries some of her belongings with her because she believes that others are trying to steal them. Which nursing action will promote trust?

Correct Answer: B

Rationale: Step 1: Initiating short, frequent contacts with the client will promote trust by establishing a consistent and supportive presence. Step 2: This approach allows the nurse to build rapport and demonstrate genuine concern for the client's well-being. Step 3: Regular interactions can help the client feel understood and supported, leading to a more trusting relationship. Step 4: By maintaining frequent contact, the nurse can monitor the client's well-being and provide reassurance as needed. Step 5: This proactive approach fosters trust and a therapeutic alliance, enhancing the client's overall care experience.

Correct Answer: C

Rationale: The correct answer is C: Evaluate the client's physical health status. This is crucial during detoxification as substance withdrawal can lead to serious physical health complications such as seizures or cardiac issues. Assessing physical health status allows for prompt intervention if needed. Obtaining a detailed substance use history (A) can provide valuable information but is not immediate priority during initial assessment. Establishing a trusting nurse-client relationship (B) is important but ensuring physical safety comes first. Determining client's readiness for change (D) is important for long-term treatment planning but not as urgent as assessing physical health status.

Correct Answer: B

Rationale: The correct answer is B: Fever and chills. This indicates a transfusion reaction because it is a common symptom of hemolytic reactions, where the body is reacting to incompatible blood. Elevated blood pressure (A) is not typically a sign of a transfusion reaction. Increased urine output (C) is more likely a sign of fluid overload. Bradycardia (D) is not a common symptom of a transfusion reaction. Fever and chills are classic signs of a transfusion reaction due to the body's immune response to the blood transfusion.

Correct Answer: B

Rationale: The correct response is B: I will notify your healthcare provider to discuss possible medication changes. This is the best choice because decreased libido is a common side effect of SSRIs that can significantly impact the client's quality of life. Consulting the healthcare provider is crucial to explore alternative treatment options or adjustments to improve the client's symptoms. Choices A, C, and D do not address the underlying issue of decreased libido and are unlikely to provide effective solutions. Choice A only acknowledges the side effect without offering a proactive solution. Choice C is unrelated to the sexual side effect and may not address the client's concerns. Choice D suggests a general lifestyle change that may not directly address the medication side effect. Consulting the healthcare provider for medication adjustments is the most appropriate action to address this specific side effect.

Correct Answer: B

Rationale: The correct answer is B: Prothrombin time (PT). Warfarin is an anticoagulant medication that works by inhibiting clotting factors. Monitoring PT is essential to ensure the patient's blood is clotting within the desired range to prevent both bleeding and clotting events. Platelet count (A) assesses the quantity of platelets, not the clotting function. Hemoglobin level (C) evaluates red blood cell count and oxygen-carrying capacity. White blood cell count (D) assesses immune function and infection risk, not clotting ability. PT is directly related to warfarin's mechanism of action, making it the most crucial parameter to monitor.