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: 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: A

Rationale: The correct answer is A because providing easily accessible finger foods throughout the day increases input, ensuring the patient with dementia receives adequate nutrition. This approach helps maintain their energy levels and prevents malnutrition. Choice B is incorrect because anorexia is not necessarily the reason for providing finger foods. Choice C is incorrect as finger foods may not necessarily assist in monitoring food intake. Choice D is incorrect as the primary rationale for providing finger foods is to increase input, not specifically to prevent constipation.

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.

Correct Answer: C

Rationale: The correct answer is C because women who are incarcerated are more likely to receive mental health services than men. This is because women in the criminal justice system often have higher rates of mental health issues compared to men. Providing mental health services to incarcerated women can help address underlying issues contributing to their criminal behavior and aid in their rehabilitation. Choice A is incorrect as mentally ill men are actually more likely to be convicted of a crime due to various factors such as lack of access to mental health services, stigma, and social circumstances. Choice B is incorrect as it generalizes without considering various factors affecting the likelihood of conviction for mentally ill women. Choice D is incorrect as it makes a broad statement about African American offenders without considering the individualized mental health needs of each offender.

Correct Answer: D

Rationale: The correct answer is D: transitional challenges. Young adults often face significant changes in various aspects of their lives such as transitioning from school to work or moving out of their parents' home. This can lead to stress, anxiety, and depression. Developmental delays (A) typically refer to delays in reaching developmental milestones during childhood. An increase in comorbidities (B) may not necessarily be the main mental health challenge faced by young adults. Polypharmacy (C) is the use of multiple medications, which is more related to physical health challenges rather than mental health challenges in young adults. In summary, transitional challenges are the main mental health challenge for young adults due to the significant life changes they experience during this period.

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: Risk for Injury. Insomnia and sleep deprivation can lead to cognitive impairment and physical fatigue, increasing the risk of accidents and injuries. The nurse's priority is ensuring the client's safety. Option B, Ineffective Coping, focuses on emotional response rather than immediate safety concerns. Option C, Deficient Knowledge, does not directly address the client's current safety issue. Option D, Anxiety, is important but may not pose an immediate threat to safety compared to the risk of injury from sleep deprivation.

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.