Which nursing intervention would help the client to meet desired outcomes when demonstrating behaviors and verbalizations indicating a lack of guilt feelings?

Correct Answer: A

Rationale: The correct answer is A because providing external limits on client behavior helps establish boundaries and consequences for inappropriate actions, promoting accountability and potentially reducing guilt-inducing behaviors. This intervention can guide the client towards more appropriate behaviors and reinforce the importance of adhering to set limits. Explanation of why the other choices are incorrect: B: Foster discussions of rationales for behavioral change - While discussing rationales for behavioral change can be beneficial, it may not directly address the lack of guilt feelings in the client. C: Implement interventions consistently by only one staff member - Consistency in interventions is important, but limiting interventions to one staff member may not be sufficient to address the underlying lack of guilt feelings. D: Encourage the client to involve self in care - Encouraging client involvement in care is important for empowerment but may not directly address the lack of guilt feelings.

Correct Answer: C

Rationale: The correct answer is C because holding the client's head steady and applying a helmet is the most appropriate intervention to prevent injury while addressing the head-banging behavior. Restraints (choice A) are not recommended as they can escalate aggression. Sedating the client (choice B) may have adverse effects. Distracting the client (choice D) does not address the safety concern directly.

Correct Answer: B

Rationale: The correct answer is B because verbal abuse poses an immediate risk to the safety and well-being of others. Addressing this behavior first is crucial to ensure a safe therapeutic environment. The other choices, A, C, and D, do not pose an immediate threat to others' safety. Client A's behavior, although inappropriate, is not directly harmful to others. Client C's demand for attention may be disruptive but does not present an immediate safety concern. Client D's history of self-mutilation is concerning but does not indicate an immediate risk to others on the unit. Prioritizing the client diagnosed with conduct disorder who is verbally abusing a peer addresses the most urgent situation.

Correct Answer: C

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.