Correct Answer: D

Rationale: The correct answer is D, engage in reality-oriented conversation. This is appropriate because it helps the patient ground themselves in reality and potentially reduce the intensity of their delusions. By discussing real-life events and situations, the patient is encouraged to recognize the disparity between their delusional thoughts and actual reality. Choice A is incorrect as simply accepting the delusion as illogical does not actively address the patient's condition. Choice B, distinguishing external boundaries, is not as effective in directly challenging the delusional thoughts. Choice C, explaining the basis for the delusions, may not be helpful initially as the patient may not be receptive to logical explanations due to their distorted thinking.

Correct Answer: A

Rationale: The correct answer is A because involving the entire family in therapy sessions allows for a more comprehensive understanding of the family dynamics and how they may be contributing to the child's issues. By including all family members, the nurse can gather diverse perspectives and insights that can inform the treatment plan. This approach also promotes family unity and collaboration in addressing the child's problems. Option B is not the best response as it lacks a clear rationale for involving the whole family. Option C, while partially true, does not directly address the question raised by the mother. Option D emphasizes the importance of every family member's perceptions but does not specifically address the benefits of involving the entire family in therapy sessions.

Correct Answer: C

Rationale: The correct answer is C. It acknowledges the client's autonomy while also addressing their concerns. First, it recognizes the client's right to discontinue treatment. Second, it opens the door for a discussion to explore the client's worries and provide support. This response shows empathy and respects the client's decision-making. Choice A is incorrect because it dismisses the client's autonomy and fails to address their concerns. Choice B is not as appropriate as it suggests only talking to the doctor, missing the opportunity for the nurse to provide immediate support. Choice D is incorrect as it invalidates the client's experience of memory loss and fails to address their concerns.

Correct Answer: A

Rationale: The correct answer is A because offering to dance with the patient shows support, builds trust, and models behavior. This approach can help the shy patient feel more comfortable and encouraged to participate. Choice B focuses on the patient's past experience, which may not directly address the current issue. Choice C isolates the patient, potentially increasing feelings of shyness. Choice D involves a third party, which may not be as effective in building a direct connection with the shy patient. Overall, option A is the most effective in directly engaging and encouraging the shy patient to participate therapeutically in the dance activity group.

Correct Answer: D

Rationale: The correct answer is D: Select and participate in one group activity per day. This outcome directly addresses the nursing diagnosis of impaired social interaction by encouraging the patient to engage in a specific social activity daily. This goal promotes social interaction, helps the patient overcome language barriers, and gradually enhances their social skills. It provides a structured approach to improve the patient's sociocultural integration. A: Show improved use of language - This choice focuses solely on language skills but does not directly address the social interaction issue. B: Demonstrate improved social skills - While this choice is related to the nursing diagnosis, it is too broad and lacks specificity compared to choice D. C: Become more independent in decision-making - This choice is not directly related to addressing impaired social interaction caused by language barriers.