The nurse is performing an admission assessment on a forensic client. Which of the following would be most important for the nurse to include when explaining the purpose of the assessment to the client?

Correct Answer: D

Rationale: Step 1: The nurse's priority is to address the client's mental health and behavioral issues to provide appropriate treatment and support. Step 2: Focusing on mental health and behavior helps establish a therapeutic relationship and assess the client's immediate needs. Step 3: Discussing specific crimes may trigger distress or legal concerns, hindering the therapeutic process. Step 4: Avoiding detailed discussions of crimes maintains client confidentiality and respects their dignity. Summary: Option D is correct because it prioritizes mental health assessment over discussing specific crimes, ensuring a client-centered approach and fostering a safe therapeutic environment. Choices A, B, and C are incorrect as they prioritize irrelevant or potentially harmful information over the client's well-being.

Correct Answer: A

Rationale: The correct answer is A: psychoeducation. This involves providing information and education about mental health conditions, treatment options, coping strategies, and resources available. This helps individuals and families understand the recovery process and available support. Creating a care plan (B) is important but not specifically focused on education. Referring to a psychiatrist (C) is more about treatment rather than education. Referring to a website (D) may not cater to individual needs or provide personalized support like psychoeducation does.

Correct Answer: A

Rationale: Step 1: Understanding the foundational principle of integrative care is recognizing the body's innate ability to heal itself. Step 2: Choice A acknowledges this principle by stating that the body can heal itself with the right tools. Step 3: This aligns with the holistic approach of integrative care, focusing on empowering the body's natural healing processes. Step 4: Other choices do not emphasize the foundational principle: - B focuses on the types of care received, not the core principle. - C mentions the source of knowledge, not the principle of self-healing. - D prioritizes curing a specific illness, not the broader concept of the body's healing capacity.

Correct Answer: B

Rationale: The correct answer is B: Help the family find funding and manpower to patch and repair the roof of their home. This is the highest priority intervention because it addresses the immediate physical safety and well-being of the family. By repairing the roof, the family will be protected from the elements, preventing further health risks and improving their living conditions. The other choices are incorrect: A: Making immunization appointments is important but not the highest priority in this situation as the family's immediate safety and living conditions are compromised. C: Determining educational readiness is not a priority when the family's basic needs such as shelter are not being met. D: Reporting the family for child abuse is not appropriate in this scenario as the family's situation is due to poverty and lack of resources, not intentional neglect.

Correct Answer: C

Rationale: The correct answer is C: Participating in relationships in which the client has control. In borderline personality disorder, individuals often struggle with issues of control and impulsivity. They may seek relationships where they can exert control to manage intense emotions and fear of abandonment. This behavior is a common manifestation of the disorder. Choices A and B are less likely as individuals with borderline personality disorder may have difficulties with group participation and openly expressing feelings due to fear of rejection or abandonment. Choice D is incorrect as individuals with this disorder often struggle with personal boundaries and may violate them in relationships.

Correct Answer: D

Rationale: The correct answer is D because a client who had a cerebrovascular accident two days ago and needs help toileting can be safely assigned to an AP. This task does not require specialized nursing knowledge or assessment skills. The AP can assist with toileting safely under the supervision of the nurse. Choices A, B, and C require nursing assessment, intervention, or evaluation of the client's condition, which should be done by a nurse. Assigning these tasks to an AP could compromise client safety and proper care.

Correct Answer: B

Rationale: Step 1: Narcolepsy is a neurological disorder characterized by excessive daytime sleepiness and sudden episodes of sleep. Obstructive sleep apnea syndrome is a condition where breathing repeatedly stops and starts during sleep. Step 2: People with narcolepsy awaken from sleep feeling unrefreshed, not rested and replenished as mentioned in choice B. Step 3: On the other hand, individuals with obstructive sleep apnea syndrome often wake up feeling tired due to disrupted sleep from breathing pauses. Step 4: Therefore, the statement in choice B correctly contrasts the post-nap feelings of individuals with narcolepsy and obstructive sleep apnea syndrome. Step 5: Choices A, C, and D are incorrect as they do not accurately differentiate between the two disorders and may mislead the audience.

Correct Answer: C

Rationale: In the working phase, clients actively engage in exploring and addressing their issues, such as learning coping strategies for anger management. This phase focuses on goal setting, problem-solving, and skill development. The nurse-client relationship has progressed beyond initial introductions (orientation phase) and rapport-building (pre-interaction phase). The termination phase is when the relationship concludes after achieving goals. Thus, the correct answer is C as it aligns with the specific client goal of anger management intervention.

Correct Answer: B

Rationale: Correct Answer: B Rationale: 1. Notify the client's physician: It is crucial to inform the client's physician immediately about the elopement to ensure appropriate medical oversight. 2. Follow facility policy: Following established protocols is essential to manage the situation effectively and maintain the client's safety. 3. Document the incident: Detailed documentation is necessary for legal and clinical purposes to track the event's specifics and subsequent actions taken. 4. Review elopement precautions: By reviewing and potentially updating elopement prevention strategies, the facility can enhance security measures to prevent future incidents. Summary: A: Involuntarily admitting the client to another facility without proper evaluation and consent is not appropriate and may violate the client's rights. C: Sending a therapeutic assistant alone to retrieve the client can be unsafe and may not address the underlying reasons for elopement. D: Involving the police in another state could escalate the situation and may not prioritize the client's mental health needs.