Which of the following would be most important for the nurse to keep in mind when establishing the nurse-patient relationship with a client with schizophrenia to promote recovery?

Correct Answer: C

Rationale: The correct answer is C because short, time-limited interactions are best for clients experiencing psychosis due to their limited attention span and potential for increased anxiety. Lengthy interactions may overwhelm the client and hinder the development of trust and rapport. A: The relationship typically develops over a short period of time - Incorrect. Building a therapeutic relationship with a client with schizophrenia takes time due to trust issues and symptom severity. B: Decisions about care are the responsibility of interdisciplinary team - Incorrect. While involving the interdisciplinary team is important, the nurse-patient relationship is crucial in promoting recovery. D: Typically, clients with schizophrenia readily engage in a therapeutic relationship - Incorrect. Clients with schizophrenia may have difficulties in engaging due to symptoms such as paranoia and disorganized thinking.

Correct Answer: C

Rationale: The correct answer is C. REM sleep and body temperature cycles are inversely related. During REM sleep, our body temperature decreases, which is essential for the body to conserve energy and maintain a state of relaxation. This decrease in body temperature during REM sleep helps promote the restoration and rejuvenation of the body. It is crucial for the nurse to convey this information accurately to the community group to emphasize the importance of quality sleep for overall health. Choice A is incorrect because there is indeed an observable relationship between REM sleep and body temperature. Choice B is incorrect as higher levels of REM sleep are associated with lower body temperatures, not higher. Choice D is incorrect as the experience of REM sleep is not directly proportional to a rise in body temperature; instead, it is inversely related.

Correct Answer: D

Rationale: The correct answer is D because the patient's behavior of being tense, vigilant, pacing, clenching fists, and staring can be indicative of potential aggression. This behavior shows signs of escalating agitation and aggression, which should be addressed promptly for safety. A: Withdrawal typically involves avoiding social interactions and showing disinterest, which does not align with the patient's behavior. B: Working through angry feelings would involve more introspective or expressive behaviors, not outward signs of potential aggression. C: Relaxation strategies would involve more calming and self-soothing behaviors, which are not exhibited by the patient in this scenario.

Correct Answer: A

Rationale: Correct Answer: A Rationale: Assessing normal sleep patterns is the initial step to understand the client's current sleep habits and identify specific disturbances in their sleep pattern. This assessment is crucial for developing an individualized care plan tailored to the client's needs. By gathering information on the client's sleep patterns, the nurse can effectively determine the underlying causes of the disturbance and implement appropriate interventions. This proactive approach ensures that interventions are evidence-based and address the client's unique situation. Summary of other choices: B: Discouraging napping during the day may be relevant but should come after assessing the client's sleep patterns to determine if daytime napping is contributing to the disturbance. C: Discouraging the use of caffeine and nicotine is important, but this intervention should be based on the assessment findings and individual client factors. D: Teaching relaxation exercises can be beneficial, but without understanding the client's specific sleep patterns and needs, it may not address the root cause of the sleep pattern disturbance.

Correct Answer: A

Rationale: The correct answer is A because it is important for children to be given clear and honest information about death to help them process their grief effectively. This choice provides the 4-year-old sister with a direct and simple explanation of her brother's death, which can help her understand the permanence of the situation. Choices B, C, and D use euphemisms or abstract concepts that may confuse or mislead the child, potentially causing more distress or misunderstanding. It is crucial to be honest and straightforward with children about death to support their emotional well-being.

Correct Answer: D

Rationale: The correct answer is D: Sensory losses. In this scenario, the older adult patient's agitation and readiness to strike out may be due to sensory losses such as hearing or vision impairment, leading to frustration and miscommunication. Assessing for sensory losses is crucial to understand the root cause of the patient's behavior and provide appropriate interventions. A: Panic disorder - This choice is incorrect as panic disorder typically presents with sudden and intense episodes of fear or anxiety, not necessarily leading to physical aggression. B: Epilepsy - This choice is incorrect as epilepsy is a neurological disorder characterized by seizures, not typically associated with sudden aggression. C: Bipolar disorder - This choice is incorrect as bipolar disorder involves distinct episodes of mania and depression, which may not directly cause the patient's behavior in this situation.

Correct Answer: C

Rationale: The correct answer is C: Administer the antacid 1 hour after the antipsychotic medication. Aluminum salts can reduce the absorption of certain medications, including antipsychotics. Giving the antacid 1 hour after the antipsychotic medication allows for adequate absorption of the antipsychotic while still providing relief from gastric symptoms. Option A would not be ideal as it may interfere with the absorption of the antipsychotic. Option B could potentially decrease the effectiveness of the antipsychotic by reducing its absorption. Option D is not recommended as aluminum salts can cause reflux when lying down, potentially worsening the patient's symptoms.

Correct Answer: C

Rationale: The correct answer is C because OCD symptoms typically worsen with stress due to increased anxiety triggering obsessions and compulsions. This understanding is crucial for the family to help manage the condition effectively. Option A is incorrect because thoughts in OCD are intrusive and involuntary. Option B is incorrect as immediate attention may reinforce the symptoms. Option D is incorrect as OCD can respond well to treatment approaches like therapy and medication.

Correct Answer: D

Rationale: The correct answer is D because when a client makes specific threats toward an identifiable person, there is a duty to warn the potential victim to prevent harm. This duty is based on the principle of duty to protect, which overrides confidentiality in cases of imminent danger. Choices A, B, and C do not necessarily involve direct threats toward a specific individual, so the duty to warn does not apply in those situations. It is important to prioritize the safety of potential victims when making decisions regarding confidentiality and duty to warn.