What intervention should the nurse include as a nonpharmacologic pain-relief intervention for chronic pain?

Correct Answer: A

Rationale: The correct answer is A: referring the client for hypnosis. Hypnosis is an evidence-based nonpharmacologic intervention for chronic pain that can help manage pain perception and improve coping mechanisms. It is safe and effective for long-term pain management. Referring for hypnosis aligns with the holistic approach to chronic pain management. Choice B: administering pain medication as prescribed is a pharmacologic intervention, not nonpharmacologic. Choice C: removing all glaring lights and excessive noise can help create a comfortable environment but may not directly address chronic pain relief. Choice D: using over-the-counter transcutaneous electric nerve stimulation is a nonpharmacologic intervention, but it may not be as effective for chronic pain as hypnosis.

Correct Answer: A

Rationale: The correct answer is A: Risk for falls R/T right-sided weakness and sedation from risperidone. This is the priority nursing diagnosis because the client's physical aggression and right-sided weakness increase the risk of falls, which can lead to further injury. The sedative effect of risperidone can further impair the client's balance and coordination, exacerbating the risk. Addressing this risk is crucial to ensure the safety and well-being of the client. Summary of other choices: B: Activity intolerance R/T right-sided weakness - While this is a relevant concern, it is not the priority as the risk of falls takes precedence. C: Disturbed thought processes R/T acting-out behaviors - While the client's behavior may be a concern, addressing the immediate risk of falls is more critical. D: Anxiety R/T change in health status and dependence on others - While anxiety may be present, addressing the risk of falls is more urgent in this situation.

Correct Answer: B

Rationale: The correct answer is B. By informing the student's instructor and the client's primary nurse, the nursing student upholds the ethical principle of veracity, which is being truthful and honest. This action ensures that the correct dosage of medication is administered to the client, preventing potential harm. Documenting the situation is essential for accurate record-keeping and accountability. Choice A is incorrect because keeping the information confidential would go against the ethical principle of veracity and could potentially harm the client. Choice C is incorrect as the decision about actions should involve healthcare professionals to ensure the client's safety and well-being, not solely the client. Choice D is incorrect because even if the client was not harmed immediately, incorrect medication dosages could still have long-term consequences, making it crucial to report the incident for proper evaluation and prevention.

Correct Answer: A

Rationale: The correct answer is A because tertiary prevention focuses on managing existing conditions to prevent further complications. Helping a person with mental illness learn to manage money falls under this category by providing support and skills to improve their quality of life. Choice B involves physical restraint, which is not a form of prevention. Choice C is an example of primary prevention as it aims to educate and prevent the initial occurrence of substance abuse. Choice D is an example of secondary prevention as it involves identifying genetic risks and providing counseling to prevent the development of diseases or conditions.

Correct Answer: B

Rationale: The correct answer is B: use congruent communication strategies. Congruent communication involves aligning verbal and nonverbal cues, showing authenticity and transparency. This is crucial when working with patients diagnosed with schizophrenia to build trust and rapport. Restating what the patient says (A) may seem insincere or robotic. Using self-revelation (C) can shift the focus from the patient to the nurse. Consistently interpreting the patient's behaviors (D) may lead to misinterpretations and breakdown in communication. Overall, using congruent communication strategies helps the nurse establish a genuine connection with the patient and promote effective therapeutic communication.