The nurse is caring for a client who has been receiving treatment for schizophrenia with chlorpromazine for the past year. It would be essential for the nurse to monitor the client for which of the following?

Correct Answer: D

Rationale: The correct answer is D: Tardive dyskinesia. Tardive dyskinesia is a potential side effect of long-term antipsychotic use, including chlorpromazine. It is characterized by involuntary repetitive movements, such as lip smacking or tongue protrusion. The nurse should monitor the client for early signs of tardive dyskinesia to prevent irreversible damage. Choices A, B, and C are incorrect: A: Weight loss is not typically associated with chlorpromazine use; in fact, weight gain is more common. B: Torticollis is a condition characterized by a twisted neck, which is not a common side effect of chlorpromazine. C: Hypoglycemia is not a known side effect of chlorpromazine; instead, it is more commonly associated with other medications like insulin or sulfonylureas.

Correct Answer: A

Rationale: The correct answer is A because it demonstrates understanding and acceptance of the child's condition, emphasizing that the child is not inherently bad. This statement shows empathy, understanding, and willingness to support the child. Choice B is incorrect because it focuses on a potential negative outcome rather than addressing the immediate needs of the child with ADHD. Choice C is incorrect because stopping medication abruptly can have negative consequences on symptom management and may not accurately assess the medication's effectiveness. Choice D is incorrect because consistency and firm boundaries are essential for children with ADHD, and allowing occasional violations of limits may not be conducive to the child's development and symptom management.

Correct Answer: B

Rationale: The correct answer is B: Transference. This term refers to the patient projecting feelings or emotions they have towards someone else, typically a significant figure from their past, onto the nurse. In this scenario, the patient is expressing comfort in talking to the nurse similar to the comfort they felt when talking to their deceased father, indicating a transference of emotions. A: Superego pertains to the internalized moral standards and values of an individual, not relevant in this context. C: Reality testing involves distinguishing between internal thoughts and external reality, which is not the focus of the patient's comment. D: Counter-transference refers to the nurse's emotional response towards the patient, not the patient's feelings towards the nurse.

Correct Answer: D

Rationale: The correct answer is D, Medical-surgical nursing skills. Evidence collection in caring for injured victims requires knowledge of assessing and treating physical injuries, which falls under the domain of medical-surgical nursing. Legal aspects (A) are important for documentation but not direct care. Testifying in court (B) and collaborating with law practitioners (C) are not essential for providing immediate care to the victim. Therefore, D is the most relevant choice.

Correct Answer: C

Rationale: The correct answer is C: client-centered care. Building trust is an essential component of client-centered care, where the nurse respects the patient's values, preferences, and needs. Trust is crucial for effective communication and collaboration in healthcare. Nursing assessment (A) focuses on gathering patient data, client teaching (B) involves educating patients, and quality improvement (D) pertains to enhancing healthcare processes. However, building trust aligns most closely with client-centered care as it emphasizes the patient's perspective and fosters a therapeutic relationship.