The nurse at the clinic is interviewing a patient who offers a number of vague somatic complaints that might not ordinarily prompt a visit to a caregiver: fatigue, back pain, headaches, and sleep disturbance. The patient seems tense, and after having spoken of the symptoms, seems reluctant to provide more information and is in a hurry to leave. The nurse can best serve the patient by:

Correct Answer: B

Rationale: The correct answer is B: Completing a structured abuse assessment protocol. Given the patient's vague complaints, tension, reluctance to provide more information, and hurry to leave, these could be signs of potential abuse. Completing a structured abuse assessment protocol allows the nurse to systematically assess for any signs of abuse, which could be contributing to the patient's somatic complaints. This approach is necessary to ensure the patient's safety and well-being. Incorrect choices: A: Asking if the patient has ever had psychiatric counseling - This choice does not directly address the potential abuse concerns indicated by the patient's behavior. C: Exploring the possibility of patient social isolation - While social isolation could be a contributing factor, the urgency to leave and reluctance to provide information are more indicative of potential abuse. D: Asking the patient to disrobe to check for signs of abuse - This choice is invasive and inappropriate without first completing a structured abuse assessment protocol to determine if abuse is likely.

Correct Answer: B

Rationale: The correct answer is B: Play therapy. Play therapy is the most suitable therapeutic intervention for a child in this scenario because it allows the child to express their feelings and experiences through play, which is a natural form of communication for children. Through play therapy, the child can act out their experiences using toys and create a safe space to process their emotions without having to verbally communicate. It helps the child release pent-up feelings and trauma in a non-threatening environment. Summary of other choices: A: Individual communication with the nurse may not be as effective as play therapy in this case as the child is not yet comfortable verbalizing their feelings. C: Family therapy may not be appropriate at this stage as the child is not ready to engage with family members about the abuse. D: Role-play with other children on the unit may not be beneficial as it can potentially trigger more anxiety and discomfort for the abused child.

Correct Answer: B

Rationale: The correct answer is B: Verbalizing an awareness of her increasingly dangerous situation. This choice is the most realistic outcome for the client as it shows an initial step towards acknowledging the severity of her situation. By verbalizing awareness, the client can begin to understand the potential dangers she faces, which is crucial for developing a safety plan and seeking appropriate help. Choice A is incorrect as it may lead to victim-blaming and does not address the root cause of the abuse. Choice C is premature as setting a goal date for divorcing her husband requires careful planning and consideration of various factors. Choice D is inappropriate as retaliation can escalate the violence and put the client at further risk. In summary, choice B is the best option as it focuses on increasing the client's awareness of her situation, which is a crucial first step towards addressing and eventually overcoming the abusive relationship.

Correct Answer: B

Rationale: The correct answer is B because Alzheimer's disease is a primary dementia that is characterized by the presence of beta-amyloid protein in neurons leading to the formation of senile plaques. This explanation is accurate as it describes the key pathological process underlying Alzheimer's disease. Choice A is incorrect because Alzheimer's disease is a primary dementia, not a secondary dementia. Choice C is incorrect because the etiology of Alzheimer's disease is not related to diet or toxic substances, so it is not treatable in that way. Choice D is incorrect because while Alzheimer's disease is irreversible, it is not treatable with antihypertensive medications as these medications are not effective in managing the disease process of Alzheimer's.

Correct Answer: B

Rationale: The correct answer is B: Bathe twice weekly with assistance. This outcome is appropriate because it takes into account the client's dementia and self-care deficit while also promoting hygiene and independence. Daily bathing may be overwhelming for the client and may not be necessary for maintaining good hygiene. Allowing the nurse to totally manage hygiene (choice C) may not promote the client's independence. Remaining free of skin diseases/lesions (choice D) is important but may not directly address the self-care deficit. Bathe twice weekly with assistance strikes a balance between promoting hygiene and respecting the client's abilities and limitations.