The nurse receives transfer of care report and recognizes the highest priority client need when learning what detail about the client?

Correct Answer: D

Rationale: The correct answer is D because the client's statement about the partner being 'sorry' for their breakup indicates potential harm or danger. This statement may suggest thoughts of retaliation or harm towards the partner, raising concerns for safety and potential violence. It should be the nurse's priority to assess the client's risk of harm to themselves or others. Explanation of why the other choices are incorrect: A: The client being silent during some interviews may indicate anxiety or distress, but it does not necessarily pose an immediate safety concern. B: A history of preeclampsia with a past pregnancy is important for medical history but does not indicate an immediate risk to the client's safety. C: The family bringing in magazines is not a critical detail that raises concerns about the client's safety or well-being.

Correct Answer: A

Rationale: The correct answer is A: To have the client choose the topic of the conversation. By asking the client to share what's on their mind, the nurse is allowing the client to lead the discussion and express their concerns or thoughts. This empowers the client to direct the conversation towards what is most important to them, promoting client-centered care and fostering a sense of autonomy. Choice B is incorrect because the purpose is not to present new ideas but to encourage the client to share their own thoughts. Choice C is incorrect as conveying interest is important in therapeutic communication but not the primary purpose of this specific technique. Choice D is incorrect as the purpose is not specifically to provide time for reflection but to allow the client to initiate the conversation.

Correct Answer: A

Rationale: The correct answer is A because seeing oneself as capable of achieving ideals and meeting demands indicates a positive self-perception and mental strength, aligning with the goal of demonstrating mentally healthy behavior. Choice B is incorrect as it describes impulsive behavior, which is not indicative of mental health. Choice C suggests aggressive and selfish behavior, which goes against mental health principles. Choice D, seeking help when needed, is important but does not directly demonstrate the achievement of mentally healthy behavior like choice A does.

Correct Answer: B

Rationale: The correct answer is B: primary prevention. By encouraging victims to describe their memories and feelings about the tornado, the nurse is promoting emotional processing and resilience, which are key components of primary prevention. This approach aims to prevent the development of long-term mental health issues by addressing immediate emotional needs. Explanation for incorrect choices: A: Triage involves prioritizing and allocating resources based on the severity of the situation. While important after a disaster, encouraging victims to share their experiences is not directly related to triage. C: Psychosocial rehabilitation focuses on restoring functioning and quality of life for individuals with existing mental health issues. This choice does not align with the scenario of addressing immediate emotional responses to a traumatic event. D: Psychiatric case management involves coordinating services for individuals with severe mental illness. This choice is not relevant in the context of supporting victims of a natural disaster in processing their emotions.

Correct Answer: D

Rationale: The correct answer is D because it aligns with the concept of cultural competence. Puerto Rican American culture values expressive body language to convey emotions. This behavior is not indicative of a histrionic personality disorder (A), sexual appeal (B), or seeking attention (C). Understanding cultural norms is crucial in interpreting patient behavior accurately.