To keep the plan of care client-centered, what important assessment should the nurse do after identifying several risk factors for substance misuse in a client?

Correct Answer: B

Rationale: The correct answer is B: perform a client strengths assessment. This is essential to keep the plan client-centered by focusing on the individual's positive attributes and resources. By identifying the client's strengths, the nurse can tailor interventions that build on these assets to empower the client in managing the risk factors for substance misuse. A: Contacting a rehab center for an intake assessment is premature without fully assessing the client's strengths and individualized needs first. C: Asking the psychiatrist to screen for depression is important but does not directly address keeping the plan client-centered and focusing on strengths. D: Completing a health assessment is necessary but does not specifically address the client's strengths and may not fully support client-centered care.

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 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.

Correct Answer: C

Rationale: The correct answer is C because during the first interview with a patient with a psychiatric disorder, it is crucial for the nurse to address relationship parameters to establish a therapeutic alliance, discuss the contract to clarify roles and expectations, ensure confidentiality to build trust, and explain termination to manage expectations. These aspects lay the foundation for a successful therapeutic relationship. A: Trust, congruence, attitudes, and boundaries - While trust and boundaries are important, they are part of relationship parameters addressed in choice C. Congruence and attitudes are more about the nurse's behavior than issues to address with the patient initially. B: Goals, resistance, unconscious motivations, and diversion - These are important aspects, but they are more relevant in later stages of therapy after a strong therapeutic alliance has been established. D: Transference, countertransference, intimacy, and developing resources - These are advanced concepts that may be addressed later in therapy as trust and rapport are established.

Correct Answer: C

Rationale: The correct answer is C because validation therapy involves acknowledging and validating the person's feelings and reality. By reiterating the patient's desire to go home and prepare dinner for her husband, the nurse validates the patient's emotions and reality, which can help reduce distress and agitation. Choice A is incorrect because it simply redirects the patient without acknowledging her feelings or reality. Choice B is incorrect because it focuses on the patient's widow status rather than validating her current feelings and beliefs. Choice D is incorrect because it introduces a potentially negative and untrue statement about the patient's husband, which could escalate the situation rather than providing validation.