The nurse is assessing a 78-year-old client who lives alone in his own home. To assess the client's instrumental activities of daily living, which question would be most appropriate to ask?

Correct Answer: D

Rationale: The correct answer is D because assessing the client's ability to go to the store and buy groceries directly evaluates their instrumental activities of daily living (IADLs), which are crucial for independent living. This question helps determine the client's mobility, cognitive function, and ability to manage finances and nutrition. Choices A and B focus more on basic activities of daily living (ADLs) related to personal hygiene and clothing changes. Choice C is related to cooking meals, which is also an IADL but may not provide as comprehensive information about the client's overall independence compared to the ability to shop for groceries.

Correct Answer: D

Rationale: Reaction formation is a defense mechanism where a person behaves in a way that is opposite to their true feelings or impulses. In this scenario, choice D demonstrates reaction formation because the client is expressing a belief that people who steal are lazy and should earn money honestly, which is opposite to their own behavior of stealing. This behavior helps the client deny their true feelings of guilt or shame about their actions. Choices A, B, and C do not exhibit reaction formation as they do not involve expressing beliefs or behaviors opposite to their true feelings or impulses.

Correct Answer: B

Rationale: The correct answer is B because it highlights the importance of checking for congruence between verbal and nonverbal communication to validate responses. This demonstrates an understanding that nonverbal cues can provide additional insights into a patient's true feelings or thoughts. Choice A is incorrect as it simply states a general observation without emphasizing the significance of nonverbal cues. Choice C is incorrect because assuming a patient's emotions based solely on body posture is not accurate or reliable. Choice D is incorrect as it undervalues the importance of nonverbal communication in understanding the complete message being conveyed.

Correct Answer: C

Rationale: The correct answer is C: "We've installed locks on all the outside doors." This statement shows an understanding of the need to prevent the patient with dementia from wandering off and getting lost or injured. Installing locks on outside doors helps to ensure the patient's safety by limiting their ability to leave the house unsupervised. This measure is crucial in providing a secure environment for someone with dementia. Explanation: A: The statement about the local police knowing the patient has wandered off before does not address the immediate need to prevent wandering and ensure safety. B: Keeping the noise level low in the house may be helpful for a patient with dementia, but it does not directly address the safety concern of wandering. D: Attaching the telephone number to the patient's shirt pocket is a good safety measure, but it does not address the primary concern of preventing the patient from wandering off.

Correct Answer: C

Rationale: The correct answer is C. Administer prescribed medication morphine for pain control. In this scenario with a 'DNR-CCO' order, the focus is on comfort care rather than resuscitation. Administering morphine for pain control aligns with the patient's wishes and provides comfort during a potentially distressing event. Calling for the code team (A) and initiating CPR (D) would go against the DNR order. Notifying the attending physician and family (B) is important but not the immediate nursing action needed during a cardiac arrest in this case.