Correct Answer: A

Rationale: The correct answer is A because an auditory hallucination involves hearing something that is not actually present. In this scenario, the man is hearing his dead wife talking to him, which is a perception without an external auditory stimulus. This illustrates an auditory hallucination. Choice B is incorrect as it describes a visual hallucination, seeing the doorbell indicator light up and hearing the bell ring. Choice C is also incorrect as it describes a visual misperception, seeing a man in the closet that turns out to be a dry cleaning bag. Choice D is incorrect as it describes a misinterpretation of a visual stimulus, mistaking a blanket for a dog.

Correct Answer: D

Rationale: A score of 6 on the MoCA tool indicates severe cognitive impairment because the MoCA is scored out of 30, with a lower score indicating more severe impairment. A score of 6 is significantly below the normal range, indicating severe cognitive deficits affecting various cognitive domains. This score would suggest significant impairment in memory, attention, language, visuospatial abilities, and executive functions. Therefore, Option D is correct. Options A, B, and C are incorrect as they suggest no, mild, or moderate impairment, which would not align with a score as low as 6 on the MoCA tool.

Correct Answer: C

Rationale: The correct answer is C, stab wound to the chest. This injury is the highest priority because it poses the greatest risk to the client's life due to potential damage to vital organs and major blood vessels. Immediate intervention is crucial to prevent severe bleeding, pneumothorax, or cardiac tamponade. Treating this injury promptly can significantly increase the client's chances of survival. The other choices are incorrect because: A: An open leg fracture, while serious, does not typically pose an immediate life-threatening risk compared to a stab wound to the chest. B: An open head injury can be severe, but not all head injuries are immediately life-threatening. D: Traumatic amputation of a thumb, while traumatic and painful, is not a priority compared to injuries that directly threaten a client's life.

Correct Answer: D

Rationale: The correct answer is D because the older adult's statement about joining his wife in heaven and plan to shoot himself indicates clear intent and imminent risk. This individual has a specific plan and timeframe, making them highest risk. Choice A is incorrect because joking about death does not necessarily indicate an imminent risk of suicide. Choice B is incorrect as past suicide attempts are a risk factor, but immediate intent is more concerning. Choice C is incorrect as the adolescent's statement is concerning, but there is no specific plan or timeframe mentioned, lowering the immediate risk compared to choice D.

Correct Answer: A

Rationale: The correct answer is A: Administer pain relief. This is the priority nursing action for a client with an electrical burn because pain management is crucial in providing comfort and reducing distress. Pain relief helps the client to relax, promotes healing, and aids in overall recovery. Administering pain relief should be the first step to ensure the client's well-being. Summary: - B: Administering oxygen may be necessary for respiratory support in some cases but is not the priority over pain relief. - C: Applying sterile dressings is important for wound care but should come after addressing pain. - D: Administering beta blockers is not indicated as the priority action for an electrical burn.