The nurse observes a client pacing in the hall. Which statement by the nurse may help the client recognize his anxiety?

Correct Answer: D

Rationale: The correct answer is D because it directly addresses the client's behavior and emotions, inviting them to express their feelings. By acknowledging the pacing and inquiring about the client's emotions, the nurse shows empathy and helps the client recognize their anxiety. Option A assumes the client is worried, which may not be accurate. Option B suggests medication without exploring the underlying issue. Option C focuses on the duration of pacing rather than the client's emotional state.

Correct Answer: C

Rationale: The most appropriate nursing intervention for a client with Alzheimer's disease experiencing emotional lability is to reduce environmental stimuli to redirect attention (Choice C). This helps to minimize triggers that can exacerbate emotional outbursts. By creating a calm and less stimulating environment, the client's emotional responses may be more stable. Attempting humor (Choice A) may not be effective as it could be misinterpreted or escalate emotions. Exploring reasons for the client's mood (Choice B) may not be feasible due to cognitive impairments. Using logic (Choice D) may not be effective as clients with Alzheimer's may have difficulty processing logical reasoning.

Correct Answer: C

Rationale: The correct answer is C: Take the client's blood pressure. Before administering chlorpromazine, it is important to assess the client's blood pressure as the medication can cause hypotension as a side effect. Monitoring blood pressure helps to ensure the client's safety and prevents potential complications. Assessing skin color and sclera (A) may be important for other assessments but not specifically related to chlorpromazine administration. Assessing the radial pulse (B) is important for monitoring cardiovascular status but may not be directly impacted by chlorpromazine. Asking the client to void (D) is not directly related to assessing for potential side effects of chlorpromazine.

Correct Answer: C

Rationale: The correct answer is C: Orientation. The nurse is assessing the client's awareness of time, place, and person, which are key components of orientation. By asking about the day, date, month, year, and location, the nurse is evaluating the client's cognitive function and ability to understand their surroundings. Confabulation (A) is the spontaneous creation of false memories, not relevant in this scenario. Delirium (B) is an acute state of confusion with rapid onset, not a specific assessment like orientation. Perseveration (D) is the repetition of a particular response, also not relevant to the assessment of orientation.

Correct Answer: B

Rationale: The correct answer is B: Development of autonomy within the family. Differentiation in family systems theory refers to the ability of individuals to maintain their own sense of self while being emotionally connected to family members. This process involves developing autonomy, where family members can express their own thoughts, feelings, and values independently. This is crucial for healthy family dynamics and individual growth. Incorrect Options: A: Cooperative action among members of the family - While cooperation is important in family systems, it does not specifically refer to the process of differentiation. C: Incongruent messages wherein the recipient is a victim - This option describes communication issues rather than differentiation. D: Maintenance of system continuity or equilibrium - This option refers to the overall stability of the family system, which is different from the process of differentiation.