Correct Answer: B

Rationale: The correct answer is B because the client screaming in the street disturbing neighbors poses a risk to themselves and others, indicating imminent danger and need for involuntary commitment for safety. Choice A, refusing medication, alone does not warrant involuntary commitment. Choice C, refusal to participate in therapy, may not indicate immediate danger. Choice D, being homeless with a mental disorder, does not automatically necessitate involuntary commitment unless there is imminent risk to self or others.

Correct Answer: C

Rationale: Axis III in the DSM-5 refers to any relevant medical conditions or physical disorders that may be impacting the patient's mental health. In this case, Chronic obstructive pulmonary disorder (COPD) would be found on Axis III as it is a physical health condition. Cocaine dependence (A) and Bipolar I disorder (B) would be found on Axis I as they are mental health disorders. Cellulitis (D) is a skin infection and would also not be found on Axis III as it is not a chronic physical health condition.

Correct Answer: B

Rationale: The correct answer is B because ethical decision-making requires examining assumptions and seeking more information before making a judgment. By questioning assumptions, the nurse can avoid biases and ensure decisions are based on accurate data. This step is crucial in understanding the full context of the ethical dilemma and considering all perspectives involved. Choices A, C, and D are incorrect because focusing on personal feelings, existing knowledge, or patient values alone may not address the root of the ethical issue or lead to a comprehensive decision-making process.

Correct Answer: D

Rationale: The correct answer is D: `We can pray together if you’d like.​` This response reflects the most appropriate spiritual nursing intervention because it acknowledges and respects the patient's strong faith. By offering to pray together, the nurse shows support, empathy, and understanding of the patient's spiritual beliefs, which can provide comfort and solace during a challenging time. Option A is incorrect as it focuses on the nurse's church rather than the patient's faith. Option B is inappropriate as it imposes the nurse's beliefs on the patient. Option C is not the best choice as guided imagery may not align with the patient's specific spiritual needs.

Correct Answer: C

Rationale: The correct answer is C: Self-care. Peplau's model emphasizes the therapeutic nurse-patient relationship, where the nurse helps the patient develop self-awareness, self-understanding, and self-care skills. By identifying self-care as a key component, the nurse promotes the patient's independence and empowerment in managing their mental illness. Incorrect choices: A: Suffering - While suffering may be a part of the patient's experience, it is not a key component in Peplau's model. B: Anxiety - Although anxiety may be present in a patient with mental illness, it is not a central focus of Peplau's model. D: Nonverbal behaviors - While nonverbal behaviors are important in communication, they are not a key component in Peplau's model, which focuses more on the therapeutic relationship and patient-centered care.