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 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: 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: B

Rationale: The correct answer is B: Staying close to a door. By staying close to a door, the nurse can have a quick exit strategy in case the situation escalates. This allows the nurse to maintain a safe distance from the potentially violent patient and increases the chances of a swift escape if needed. Using protective devices (A) can be helpful but may not always be accessible in a community clinic setting. Keeping the door closed for privacy (C) may limit escape routes and hinder quick exit. Wearing inexpensive jewelry to distract the patient (D) is not a safe or effective strategy in managing a potentially violent situation.

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.