Which statement made by a patient during an initial assessment interview should serve as the priority focus for the plan of care?

Correct Answer: D

Rationale: The correct answer is D because it indicates a potential serious mental health issue that requires immediate attention. Hearing evil voices commanding harmful actions may suggest psychosis or schizophrenia, posing a risk to the patient and others. This statement highlights the need for a thorough psychiatric evaluation and appropriate intervention. Choices A, B, and C are less concerning and do not pose an immediate threat, focusing on trust issues or perceptions of luck and relationships. Therefore, addressing the patient's hallucinations should be the priority focus for the plan of care.

Correct Answer: A

Rationale: The correct answer is A because assessing the patient's suicidal thoughts and plan is the priority in this situation to ensure patient safety. By asking about suicidal ideation, the nurse can determine the level of risk and take appropriate actions to prevent self-harm. Choice B is incorrect as encouraging the patient to talk about their feelings is important but not the priority when immediate safety is at stake. Choice C is incorrect as simply reassuring the patient without assessing their suicidal ideation can be dangerous if the patient is at high risk of self-harm. Choice D is also incorrect as providing positive affirmations and support may not address the underlying risk of suicidal ideation.

Correct Answer: B

Rationale: The correct answer is B because staying with a tearful patient demonstrates empathy and emotional support, fostering a therapeutic relationship that can enhance growth. This action shows the patient that their feelings are valid and valued, promoting trust and openness. Choices A, C, and D do not directly address the emotional needs of the patient or show positive regard, which is essential for growth in this context. Making rounds daily focuses on tasks, administering medication is necessary but not directly related to emotional support, and examining personal feelings about a patient is more reflective than actively showing support.

Correct Answer: A

Rationale: The correct answer is A. Asking the patient directly about thoughts of self-harm or suicide is the priority intervention because it allows the nurse to assess the patient's risk and take appropriate actions to ensure safety. It is essential to address potential suicidal ideation promptly. Encouraging group therapy (B) may be beneficial but is not as urgent as assessing for suicidal thoughts. Offering reassurance and support (C) is important but does not directly address the risk of suicide. Monitoring for signs of agitation or psychotic symptoms (D) is also important but not as crucial as directly assessing for suicidal ideation.

Correct Answer: A

Rationale: The correct answer is A: Nonverbal communication. In this scenario, the patient's lack of eye contact, lowered chin, and looking at the floor all indicate nonverbal cues. Nonverbal communication plays a crucial role in conveying feelings and emotions. The patient's body language suggests feelings of sadness, low self-esteem, or discomfort, which are common in major depressive disorder. Nonverbal communication is an essential aspect of interpersonal communication and can provide valuable insights into a person's emotional state. Summary: B: A message filter - Incorrect. A message filter refers to factors that distort or block communication, such as noise or distractions. The patient's behavior does not represent filtering of messages. C: A cultural barrier - Incorrect. Cultural barriers involve differences in norms, values, or communication styles. The patient's nonverbal cues are more likely related to their emotional state rather than cultural factors. D: Social skills - Incorrect. Social skills involve the ability to interact effectively with others. The