The nurse is counseling a family with two parents and two children, ages 8 and 10 years. The mother complains that the children are constantly fighting and have intense sibling rivalry. Which statement would be most appropriate when advising the parents about how to respond to the sibling rivalry?

Correct Answer: A

Rationale: Step 1: Acknowledge individuality - By reacting to each child as unique individuals with their own talents and interests, parents can promote a sense of identity and reduce competition. Step 2: Encouraging positive interactions - Fostering cooperation rather than simply demanding it can help improve sibling relationships. Step 3: Address underlying issues - By focusing on individual needs and interests, parents can address root causes of rivalry rather than just surface behaviors. Step 4: Promoting healthy relationships - Encouraging children to appreciate each other's strengths and differences can lead to a more harmonious sibling dynamic. Summary: Choice A is correct as it addresses the core issues of sibling rivalry by promoting individuality and positive interactions. Choices B, C, and D are incorrect as they do not address the underlying causes of rivalry, promote unhealthy dynamics, or offer effective solutions.

Correct Answer: B

Rationale: The correct answer is B. This outcome is specific, measurable, achievable, relevant, and time-bound (SMART). It focuses on discussing behaviors impeding social interaction, promoting self-awareness, and facilitating therapeutic communication. Choice A is too broad and lacks specificity. Choice C addresses specific behaviors but lacks a focus on self-awareness or communication. Choice D addresses anxiety management, which is not directly related to impaired social interaction. In summary, choice B is the most appropriate as it directly addresses the nursing diagnosis and promotes therapeutic communication and self-reflection.

Correct Answer: A

Rationale: The correct answer is A because four-point restraints are used for clients who pose an imminent danger to themselves or others due to violent behavior, such as being hostile and threatening. Restraints should only be utilized as a last resort to ensure safety. Choices B, C, and D do not warrant the use of restraints as they do not involve immediate physical harm or danger. De-escalation techniques and alternative interventions should be attempted before resorting to restraint use.

Correct Answer: A

Rationale: The correct answer is A. Self-injurious behavior in individuals with borderline personality disorder is often a maladaptive coping mechanism used to relieve intense emotional distress or stress. This behavior is a way for the individual to externalize internal pain and gain a sense of control. It is important for the nurse to provide accurate information to the client's sister. Choice B is incorrect because self-injurious behavior in BPD is not typically used to calm or sedate individuals. Choice C is incorrect because self-injury is not usually a mechanism to avoid delusional thinking in BPD. Choice D is incorrect because while mood swings are common in BPD, self-mutilation is not typically used to slow them down.

Correct Answer: A

Rationale: The correct answer is A because not allowing a patient to have visitors violates their right to social interaction and support. Patients have the right to visitors unless it poses a risk to their health or safety. Choice B is not a violation as searching belongings is a standard procedure for safety. Choice C is not a violation as placing a patient on continuous observation is necessary for their safety. Choice D is not a violation as using physical restraint is justified to prevent harm to staff or other patients.