The nurse develops a countertransference reaction. This is evidenced by:

Correct Answer: A

Rationale: The correct answer is A because revealing personal information to the client is a sign of countertransference. Countertransference occurs when the nurse projects their own feelings onto the client, blurring professional boundaries. Revealing personal information can indicate the nurse is overly involved or emotionally attached, impacting the therapeutic relationship. Choice B is incorrect because focusing on the client's feelings is a part of the therapeutic process and not necessarily indicative of countertransference. Choice C is incorrect as confronting discrepancies is a clinical intervention aimed at promoting insight, not necessarily a sign of countertransference. Choice D is incorrect as the client feeling anger towards the nurse who resembles his mother may be a transference reaction, not countertransference.

Correct Answer: D

Rationale: The correct answer is D because informing the family about the potential effectiveness of medication in treating the distressing symptoms of schizophrenia is crucial. This information provides hope and encourages the family to support the individual in seeking appropriate treatment. Understanding that treatment is available can alleviate anxiety and promote acceptance. Choices A, B, and C are incorrect because while they provide valuable information, they are not as essential in the initial teaching session as knowing that treatment can help manage the symptoms.

Correct Answer: C

Rationale: The most appropriate nursing intervention for a client with Alzheimer's disease experiencing emotional lability is to reduce environmental stimuli to redirect attention (Choice C). This helps to minimize triggers that can exacerbate emotional outbursts. By creating a calm and less stimulating environment, the client's emotional responses may be more stable. Attempting humor (Choice A) may not be effective as it could be misinterpreted or escalate emotions. Exploring reasons for the client's mood (Choice B) may not be feasible due to cognitive impairments. Using logic (Choice D) may not be effective as clients with Alzheimer's may have difficulty processing logical reasoning.

Correct Answer: C

Rationale: The correct answer is C: Take the client's blood pressure. Before administering chlorpromazine, it is important to assess the client's blood pressure as the medication can cause hypotension as a side effect. Monitoring blood pressure helps to ensure the client's safety and prevents potential complications. Assessing skin color and sclera (A) may be important for other assessments but not specifically related to chlorpromazine administration. Assessing the radial pulse (B) is important for monitoring cardiovascular status but may not be directly impacted by chlorpromazine. Asking the client to void (D) is not directly related to assessing for potential side effects of chlorpromazine.

Correct Answer: C

Rationale: The correct answer is C: Orientation. The nurse is assessing the client's awareness of time, place, and person, which are key components of orientation. By asking about the day, date, month, year, and location, the nurse is evaluating the client's cognitive function and ability to understand their surroundings. Confabulation (A) is the spontaneous creation of false memories, not relevant in this scenario. Delirium (B) is an acute state of confusion with rapid onset, not a specific assessment like orientation. Perseveration (D) is the repetition of a particular response, also not relevant to the assessment of orientation.