Correct Answer: D

Rationale: The correct answer is D because the elderly client's behavior indicates a potential danger to themselves or others due to confusion and disruptive behavior, which are criteria for involuntary commitment.
Choice A does not pose an immediate threat.
Choice B involves a refusal of medication, but does not demonstrate immediate danger.
Choice C, although homeless and diagnosed with a mental disorder, does not exhibit behavior indicating imminent harm.

Correct Answer: A

Rationale:
Correct
Answer: A


Rationale: Option A is the correct choice because it offers the client a sense of autonomy and choice in the situation. By giving the client the option to choose between the red or green shirt, the nurse respects the client's dignity and independence. This approach promotes a collaborative and respectful relationship between the nurse and the client, which can enhance trust and cooperation in the care process.

Summary of Incorrect

Choices:
B: This option uses a confrontational and judgmental tone, which can lead to defensiveness and resistance from the client.
C: This option is forceful and does not consider the client's feelings or preferences, which can lead to increased distress and resistance.
D: This option dismisses the client's lack of self-care as a symptom of the disorder, which can undermine the client's sense of agency and discourage them from engaging in self-care activities.

Correct Answer: D

Rationale: The correct response is D: A relapse plan helps your recovery by recognizing symptoms of schizophrenia and provides steps to follow if symptoms are getting worse. This response is correct because a relapse plan is crucial for individuals with schizophrenia to manage their condition effectively. It helps the client identify early warning signs of relapse, such as changes in behavior or mood, and provides specific steps to take if those symptoms worsen. By following the plan, the client can prevent a full-blown relapse and maintain stability in their mental health.

Option A is incorrect because it focuses on coping strategies rather than relapse prevention. Option B is incorrect as it pertains to living, housing, and working needs rather than relapse planning. Option C is incorrect because it erroneously suggests that a relapse plan is about hospitalization rather than symptom recognition and management.

Correct Answer: C

Rationale: The correct answer is C: Secure the restraints using a quick-release tie. This is the correct action because quick-release ties allow for rapid removal in case of an emergency, ensuring the client's safety.
Choice A is incorrect because restraints should be removed every 2 hours, not 4.
Choice B is incorrect as restraints should not be attached to the side rails to prevent injury.
Choice D is incorrect as two fingers, not four, should fit under the restraints to ensure proper circulation.

Correct Answer: D

Rationale: The correct answer is D because the elderly client is displaying behavior that poses an immediate danger to themselves and others, indicating a need for involuntary commitment for their safety and the safety of the community. Refusing medication or therapy (choices A and
B) does not necessarily warrant involuntary commitment unless it poses immediate harm. Homelessness and mental disorder (choice
C) alone do not justify involuntary commitment. In this case, the client's behavior of confusion, screaming obscenities, and disturbing neighbors is a clear indication of a severe mental health issue that requires immediate intervention through involuntary commitment.