The nurse is assessing a patient's immediate and short-term memory. Which of the following would be most appropriate?

Correct Answer: C

Rationale: The correct answer is C because the nurse is assessing immediate and short-term memory. Giving the patient three words to recite now and then in 5 minutes tests both immediate recall and short-term memory retention. This task assesses the patient's ability to retain information over a brief period, which is crucial for evaluating memory function. In contrast, options A, B, and D involve different memory processes or timeframes and are not as directly relevant to assessing immediate and short-term memory. Option A focuses on long-term memory, option B involves problem-solving skills, and option D primarily tests orientation rather than memory retention.

Correct Answer: B

Rationale: The correct answer is B: use congruent communication strategies. Congruent communication involves aligning verbal and nonverbal cues, showing authenticity and transparency. This is crucial when working with patients diagnosed with schizophrenia to build trust and rapport. Restating what the patient says (A) may seem insincere or robotic. Using self-revelation (C) can shift the focus from the patient to the nurse. Consistently interpreting the patient's behaviors (D) may lead to misinterpretations and breakdown in communication. Overall, using congruent communication strategies helps the nurse establish a genuine connection with the patient and promote effective therapeutic communication.

Correct Answer: B

Rationale: The correct answer is B because the female reporting still hearing her daughter's pleas for help is exhibiting symptoms characteristic of acute stress reaction, a common response to traumatic events like a major fire. This symptom indicates a re-experiencing of the traumatic event, known as intrusion, which is a key feature of acute stress reactions. This can include vivid memories, flashbacks, or hearing sounds related to the traumatic event. Choices A, C, and D do not align with acute stress reactions. A male with mood swings between mania and depression (Choice A) is more likely experiencing bipolar disorder. A male repeating 'I don't understand what's going on?' (Choice C) may indicate confusion or disorientation rather than acute stress reaction. A female rocking her young son and repeating 'it will be okay' (Choice D) may be demonstrating a coping mechanism rather than a symptom of acute stress reaction.

Correct Answer: A

Rationale: The correct answer is A: Risk for falls R/T right-sided weakness and sedation from risperidone. This is the priority nursing diagnosis because the client's physical aggression and right-sided weakness increase the risk of falls, which can lead to further injury. The sedative effect of risperidone can further impair the client's balance and coordination, exacerbating the risk. Addressing this risk is crucial to ensure the safety and well-being of the client. Summary of other choices: B: Activity intolerance R/T right-sided weakness - While this is a relevant concern, it is not the priority as the risk of falls takes precedence. C: Disturbed thought processes R/T acting-out behaviors - While the client's behavior may be a concern, addressing the immediate risk of falls is more critical. D: Anxiety R/T change in health status and dependence on others - While anxiety may be present, addressing the risk of falls is more urgent in this situation.

Correct Answer: B

Rationale: The correct answer is B. By informing the student's instructor and the client's primary nurse, the nursing student upholds the ethical principle of veracity, which is being truthful and honest. This action ensures that the correct dosage of medication is administered to the client, preventing potential harm. Documenting the situation is essential for accurate record-keeping and accountability. Choice A is incorrect because keeping the information confidential would go against the ethical principle of veracity and could potentially harm the client. Choice C is incorrect as the decision about actions should involve healthcare professionals to ensure the client's safety and well-being, not solely the client. Choice D is incorrect because even if the client was not harmed immediately, incorrect medication dosages could still have long-term consequences, making it crucial to report the incident for proper evaluation and prevention.