The nurse is caring for a client diagnosed with delirium who has been brought for treatment by his son. While taking the client's history, which question would be most appropriate for the nurse to ask the client's son?

Correct Answer: A

Rationale: The correct answer is A: "Has your father taken any medications recently?" This question is most appropriate because delirium can be caused by medication side effects. By asking about recent medications, the nurse can gather important information to help identify potential causes of the client's delirium. Summary of other choices: B: "Are you aware of your father falling or injuring his head in any way?" - This question focuses on physical trauma, which may not necessarily be related to the client's delirium. C: "Has your father had a recent stroke?" - While a stroke can cause delirium, assuming a stroke without evidence may lead to incorrect assessment and treatment. D: "Has your father experienced any major losses recently?" - This question is more related to emotional stressors and may not directly address the potential medical causes of delirium.

Correct Answer: D

Rationale: The correct answer is D: Ego. The ability to form mutually satisfying relationships is a function of the ego in Freud's personality structure. The ego mediates between the id's instinctual drives and the superego's moral constraints, allowing individuals to interact with others in a socially acceptable manner. The ego helps balance personal desires with societal norms, enabling individuals to navigate relationships effectively. Incorrect Choices: A: Defense mechanisms - Defense mechanisms are strategies used by the ego to manage anxiety and protect the individual from distressing thoughts or feelings. While defense mechanisms play a role in coping with conflicts, they are not directly responsible for forming satisfying relationships. B: Unconscious - The unconscious contains repressed thoughts, memories, and desires that influence behavior. Although the unconscious plays a significant role in shaping personality, the ability to form satisfying relationships is not solely attributed to the unconscious. C: Id - The id represents innate, primal drives seeking immediate gratification. While the id influences behavior and desires, it is

Correct Answer: A

Rationale: The correct answer is A: "Has your father taken any medications recently?" This question is most appropriate because delirium can be caused by medication side effects. By asking about recent medications, the nurse can gather important information to help identify potential causes of the client's delirium. Summary of other choices: B: "Are you aware of your father falling or injuring his head in any way?" - This question focuses on physical trauma, which may not necessarily be related to the client's delirium. C: "Has your father had a recent stroke?" - While a stroke can cause delirium, assuming a stroke without evidence may lead to incorrect assessment and treatment. D: "Has your father experienced any major losses recently?" - This question is more related to emotional stressors and may not directly address the potential medical causes of delirium.

Correct Answer: A

Rationale: The correct answer is A: Pre-interaction phase. In this phase, the nurse is preparing to meet the client, gathering information, and examining personal feelings and biases. By exploring feelings about working with an abused woman, the nurse is engaging in self-reflection and preparing to approach the interaction with awareness and sensitivity. The other choices are incorrect because in the orientation phase the nurse establishes rapport, in the working phase interventions are implemented, and in the termination phase the nurse evaluates outcomes and prepares for closure, none of which align with exploring personal feelings before meeting the client.

Correct Answer: B

Rationale: The correct answer is B: Description of information about pertinent legal and court proceedings that are pending. Rationale: Understanding legal and court proceedings is crucial for a forensic client as it directly impacts their current situation and future outcomes. Providing this information can empower the client to make informed decisions and actively participate in their legal process, promoting autonomy and self-advocacy. Summary: A: While genetic and neurologic factors can contribute to criminal behavior, focusing solely on these aspects may not be the most immediate concern for the client's current needs. C: Nutrition and exercise are important for overall well-being but may not be the top priority when dealing with legal matters. D: Connecting the client's family to community providers is beneficial, but understanding legal proceedings is more urgent for the client's immediate needs.

Correct Answer: C

Rationale: The correct answer is C: Identify early internal cues of distress. This is the first step because recognizing early signs of distress can help the client intervene before the psychotic episode escalates. By identifying these cues, the client can implement coping strategies and prevent the hallucinations from worsening. Explanation for incorrect choices: A: Using skills to tolerate painful feelings is important, but identifying early cues is crucial for early intervention. B: Deep abdominal breathing can help with relaxation, but it may not address the underlying distress leading to the hallucinations. D: Referring to cards listing symptoms is less effective as it focuses on recognizing symptoms rather than proactively managing distress cues.

Correct Answer: A

Rationale: The correct answer is A: wraparound services. This type of service provides comprehensive and individualized care that addresses the multiple needs of acutely ill clients, leading to better outcomes. It includes coordination of various services such as medical, psychological, social, and community support. This approach ensures holistic care and continuity of services, promoting recovery and reducing relapses. Summary: B: Community health services may offer some support but lack the personalized and comprehensive approach of wraparound services. C: Facility mental health services focus on treatment within a specific setting and may not address the broader needs of the client. D: Individual therapy services, while beneficial, may not be sufficient for acutely ill clients who require a more holistic and coordinated approach.

Correct Answer: C

Rationale: The correct answer is C: Resilience. Christopher's ability to form positive relationships, excel in school, and maintain high academic performance despite experiencing neglect indicates resilience. Resilience refers to the ability to adapt positively in the face of adversity. His behavior shows that he is able to overcome his challenging circumstances and thrive. Temperament (A) refers to inherent traits that influence behavior, genetic factors (B) may play a role but do not fully explain his response, and the paradoxical effects of neglect (D) are not the strongest explanation in this context.

Correct Answer: D

Rationale: The correct answer is D: Engage in a power struggle. Engaging in a power struggle can escalate the situation by challenging the individual's sense of control and leading to increased anger and aggression. This behavior can further provoke the individual and worsen the situation. A: Using a soft tone of voice may not address the underlying issues causing the anger and can be perceived as patronizing. B: Moving away in fear can demonstrate avoidance behavior and may not effectively address the situation. C: Using simple words to communicate may not address the power dynamic at play and may not de-escalate the situation effectively. In summary, engaging in a power struggle can exacerbate the situation, while the other choices may not effectively address the root cause of the anger and aggression displayed by Larry.