The nurse is caring for a homeless client who has been seen in the mobile clinic every week for the past month because of a foot infection. Which nursing diagnosis would the nurse most likely identify as the priority?

Correct Answer: B

Rationale: The correct answer is B: Ineffective Health Maintenance related to homelessness. This is the priority nursing diagnosis because the client's foot infection needs immediate attention to prevent complications. Ineffective Health Maintenance addresses the client's inability to manage health and seek medical care, which is crucial in this case. A: Social Isolation is not the priority as the client is receiving regular care and interaction in the mobile clinic. C: Chronic Low Self-Esteem may be a concern but is not as urgent as addressing the foot infection. D: Imbalanced Nutrition is not directly related to the client's current issue of a foot infection.

Correct Answer: B

Rationale: The correct answer is B: Rice with black beans. This choice is correct because it is a high-fiber, plant-based meal that is low in protein, which is important for a client with hepatic encephalopathy. Rice and black beans provide complex carbohydrates and fiber, aiding in ammonia detoxification without increasing protein intake. The other choices are incorrect because: A: A sandwich and milkshake are high in protein and may exacerbate hepatic encephalopathy. C: Cottage cheese and tuna lettuce are high in protein, which can lead to increased ammonia production. D: Three-egg omelette with low-sodium ham is high in protein, which is not recommended for clients with hepatic encephalopathy.

Correct Answer: D

Rationale: The correct answer is D because insomnia, particularly early morning awakening, is a common symptom of major depressive disorder. This symptom is often associated with the inability to fall back asleep and can lead to significant fatigue and impairment during the day. It is important to note that sleep disturbances are a key criterion for diagnosing depression. A, B, and C are incorrect because restlessness (choice A) is more commonly associated with anxiety disorders, excessive studying for future goals (choice B) may indicate high achievement motivation rather than depressive symptoms, and unintentional weight loss (choice C) can be a sign of various medical conditions but is not specific to major depressive disorder.

Correct Answer: A

Rationale: The correct answer is A because it shows a lack of understanding of a suicide safety plan. This statement indicates an awareness of triggers but does not demonstrate any coping strategies or steps to prevent suicide. In contrast, choices B, C, and D all show elements of a safety plan - engaging in physical activity, relying on a supportive individual, and carrying a suicide prevention resource. In summary, A does not include any proactive measures to address suicidal thoughts compared to B, C, and D.

Correct Answer: A

Rationale: The correct answer is A: Acceptance that death is a natural part of life. This factor is crucial for hospice nurses as it enables them to approach end-of-life care with compassion and understanding. By accepting death as a natural process, the nurse can provide respectful care without fear or denial. Possessing excellent nursing skills (B) is important but not as impactful as having the right mindset towards death. A healthy personal life (C) can contribute to overall well-being but may not directly impact the nurse's ability to provide respectful care. While the desire to work with both the patient and family (D) is important, it is the acceptance of death that underpins the nurse's ability to provide professional care in the hospice setting.