Choice A reason: This statement reflects a misunderstanding of the situation. Delirium is an acute, reversible condition often triggered by infections such as urinary tract infections. Long-term care placement is not automatically indicated once delirium resolves, especially since the client was living independently prior to hospitalization. Planning for long-term care prematurely assumes permanent cognitive decline, which is not consistent with delirium’s clinical course.

Choice B reason: Respite care is designed to provide temporary relief for caregivers of individuals with chronic conditions or long-term care needs. Since the client was living independently before admission and delirium is expected to resolve after treatment of the infection, respite care is not necessary at this point. This statement suggests the adult child believes ongoing caregiver support will be required, which is inaccurate for this clinical scenario.

Choice C reason: This statement demonstrates accurate understanding. Delirium is characterized by acute onset of confusion, disorientation, and fluctuating mental status, often secondary to an underlying medical condition such as infection. Once the infection is treated and the acute illness resolves, the delirium typically subsides, and the client’s baseline cognitive function returns. Recognizing that the confusion is temporary and reversible shows that the teaching has been effective.

Choice D reason: Obtaining a permanent identification bracelet is more appropriate for clients with chronic, progressive cognitive disorders such as dementia or Alzheimer’s disease, where confusion and wandering are persistent risks. Since delirium is reversible and not a permanent condition, this intervention is unnecessary. This statement reflects a misunderstanding of the difference between delirium and dementia.

Choice A reason: Encouraging rest periods is anticipated because clients experiencing mania often have decreased need for sleep and heightened psychomotor activity. Structured rest periods help reduce exhaustion, stabilize mood, and prevent escalation of manic symptoms. Rest periods also promote recovery by counteracting the hyperactivity and insomnia commonly associated with mania.

Choice B reason: Daily weights are anticipated because clients with mania often neglect nutrition due to distractibility, hyperactivity, and poor insight. Monitoring weight provides objective data on nutritional status and helps the healthcare team intervene early if significant weight loss occurs. This is critical since malnutrition can worsen physical health and exacerbate psychiatric symptoms.

Choice C reason: Increasing environmental stimuli is contraindicated because clients with mania are already overstimulated. Additional stimuli can intensify agitation, distractibility, and restlessness, worsening the manic episode. The therapeutic environment should instead be calm, structured, and low-stimulation to promote focus and reduce hyperactivity.

Choice D reason: Offering finger foods is anticipated because clients with mania often cannot sit still long enough to consume a full meal. Finger foods allow them to eat while pacing or moving, ensuring adequate caloric intake despite their inability to remain seated. This intervention directly addresses nutritional deficits while accommodating the client’s psychomotor agitation.

Choice E reason: Applying restraints is contraindicated unless the client poses an immediate danger to themselves or others. Mania is best managed through therapeutic interventions such as medication, structured environment, and supportive care. Restraints can increase agitation, cause trauma, and damage the therapeutic relationship. They are not indicated in this scenario since the client is restless but not violent or self-harming.

Choice A reason: Lanugo is a fine, downy hair that develops on the body as a compensatory mechanism in clients with anorexia nervosa due to severe malnutrition and low body fat. It is not typically associated with bulimia nervosa, since bulimia involves recurrent binge eating followed by compensatory behaviors such as vomiting or laxative use, but does not usually result in the same degree of starvation seen in anorexia.

Choice B reason: Dental caries are expected in bulimia nervosa because repeated self-induced vomiting exposes teeth to gastric acid. This acid erodes enamel, leading to tooth decay, sensitivity, and caries. This is a hallmark physical finding in bulimia and directly reflects the purging behavior characteristic of the disorder.

Choice C reason: Cold extremities are more commonly associated with anorexia nervosa due to severe malnutrition, hypothermia, and poor circulation from low body fat. Clients with bulimia nervosa may have normal weight or even be overweight, so cold extremities are not a typical finding.

Choice D reason: Amenorrhea is more characteristic of anorexia nervosa due to extreme caloric restriction and low body fat, which disrupts hormonal regulation of the menstrual cycle. While menstrual irregularities can occur in bulimia nervosa, amenorrhea is not a defining or expected finding.

Choice A reason: Anticipatory grief refers to the emotional response experienced before an actual loss occurs, such as when a loved one is terminally ill and death is expected. It allows individuals to begin processing the loss in advance. In this case, the partner has already died, and the grief is occurring years after the event, not before. Therefore, anticipatory grief does not apply.

Choice B reason: Exaggerated grief is characterized by extreme, disabling reactions to loss, often manifesting as self-destructive behaviors, severe depression, or suicidal ideation. While the client has withdrawn socially, there is no evidence of dangerous or self-harming behaviors described. The presentation is more consistent with prolonged sadness and social withdrawal rather than exaggerated grief.

Choice C reason: Chronic grief is persistent, prolonged grief that continues for years after the loss, interfering with normal functioning and daily life. The client’s ongoing social withdrawal and lack of participation in regular activities three years after the partner’s death clearly indicate unresolved grief that has become chronic. This is the most accurate description of the client’s condition.

Choice D reason: Disenfranchised grief occurs when a person’s loss is not socially recognized or supported, such as the death of an ex-spouse, a pet, or a stigmatized relationship. In this scenario, the client’s partner’s death is a socially acknowledged loss, and the issue is not lack of recognition but persistence of grief. Therefore, disenfranchised grief does not fit the situation.

Choice A reason: Sitting with the client during mealtimes is an essential intervention because clients with bipolar disorder, especially during manic episodes, often have poor appetite and difficulty focusing long enough to eat. Direct support ensures nutritional intake, prevents further weight loss, and provides structure. It also reduces the risk of malnutrition and dehydration, which are common complications in manic states.

Choice B reason: Turning on the television for the client is not therapeutic. Clients in manic episodes are easily overstimulated, and television can increase agitation, distractibility, and hyperactivity. Instead of calming the client, it may worsen confusion and disorientation. Therefore, this intervention is inappropriate.

Choice C reason: Removing sharp objects from the client’s room is a critical safety measure. Clients with bipolar disorder experiencing mania may act impulsively, and the risk of self-harm or accidental injury is high. Ensuring the environment is free of dangerous objects reduces the likelihood of harm and supports safe management of the client’s agitation.

Choice D reason: Observing the client every 15 minutes is necessary for safety monitoring. The client is hyperactive, confused, and disoriented, which increases the risk of injury, aggression, or unpredictable behavior. Frequent observation allows early detection of escalating agitation and ensures timely intervention. This is a standard safety protocol in acute psychiatric care.

Choice E reason: Providing a low-protein diet is not indicated. Clients with bipolar disorder do not require protein restriction; in fact, adequate protein intake is important for maintaining energy and nutritional balance. Restricting protein could worsen malnutrition and weight loss. This intervention is inappropriate.

Choice F reason: Offering the client physical activities is beneficial because it provides a safe outlet for excess energy during manic episodes. Structured physical activity helps reduce agitation, channel hyperactivity, and promote better sleep. It also decreases restlessness and supports overall emotional regulation. Activities should be simple, noncompetitive, and safe to avoid overstimulation.

Choice A reason: Dissociation involves a disruption in consciousness, memory, identity, or perception of the environment. It is often seen when individuals detach from reality to avoid distressing emotions or experiences. In this case, the family member is not detaching from reality or experiencing a break in consciousness. Instead, they are expressing anger outwardly toward the provider. Therefore, dissociation does not apply.

Choice B reason: Rationalization is the use of logical-sounding explanations to justify or excuse unacceptable feelings or behaviors. For example, someone might say, “It was better this way” to justify a loss. The family member is not attempting to justify or excuse the death with reasoning; they are instead directing anger toward the provider. Thus, rationalization is not the defense mechanism being used.

Choice C reason: Repression is the unconscious blocking of unacceptable thoughts, feelings, or memories from awareness. It is a defense mechanism that prevents distressing emotions from surfacing. In this scenario, the family member is openly expressing anger and blame, not unconsciously suppressing emotions. Therefore, repression is not the correct mechanism.

Choice D reason: Displacement occurs when emotions are redirected from their original source to a safer or more acceptable target. The family member is experiencing grief and anger due to the parent’s death but is directing that anger toward the provider instead of confronting the painful reality of losing their parent. This redirection of emotions is a classic example of displacement, making it the correct answer.

Rationale for PET scan: A PET scan of the head is anticipated because the client is showing progressive cognitive decline, memory loss, and disorientation. Neuroimaging is appropriate to rule out structural or metabolic causes such as stroke, tumors, or neurodegenerative disease. This helps differentiate dementia from other neurological conditions.

Rationale for physical examination: A physical exam is anticipated because it provides a baseline assessment of the client’s overall health, identifies comorbid conditions, and evaluates neurological status. Physical findings can guide further diagnostic testing and management.

Rationale for MMSE: Administering the Mini Mental State Examination is anticipated because it is a standardized tool used to assess cognitive function, memory, orientation, and problem-solving ability. Given the client’s symptoms of forgetfulness, disorientation, and difficulty with daily tasks, the MMSE will help quantify cognitive impairment and track progression.

Rationale for medication review: Reviewing all prescribed and over-the-counter medications is anticipated because certain drugs can contribute to confusion, memory loss, or delirium. Polypharmacy and inappropriate medication use are common in older adults and can mimic or worsen dementia symptoms. Identifying and adjusting medications is a critical step in care.

Rationale for inpatient behavioral health admission: Admission to a behavioral health unit is not indicated at this stage. The client’s symptoms are consistent with progressive dementia rather than an acute psychiatric crisis. The focus should be on diagnostic evaluation, outpatient management, and support rather than psychiatric hospitalization

Choice A reason: Allowing the client to eat in their room is not appropriate because clients with anorexia nervosa often isolate themselves and may attempt to avoid eating or hide food. Supervised meals in a communal or monitored setting are necessary to ensure adequate intake and prevent food avoidance behaviors.

Choice B reason: Obtaining vital signs only once per day is insufficient. Clients with anorexia nervosa are at risk for severe complications such as bradycardia, hypotension, hypothermia, and electrolyte imbalances. Frequent monitoring is required to detect early signs of medical instability. Once daily vital signs would miss important changes.

Choice C reason: Weighing the client daily after the first voiding is the correct intervention. This ensures consistency and accuracy in monitoring weight trends, as voiding eliminates the variable of bladder volume. Daily weights are essential for tracking progress, evaluating treatment effectiveness, and identifying rapid changes that may indicate medical risk.

Choice D reason: Allowing the client to determine their daily calorie intake is inappropriate because individuals with anorexia nervosa often severely restrict calories. Nutritional intake must be carefully planned and supervised by the healthcare team to promote gradual weight restoration and prevent refeeding syndrome.

Choice A reason: A residential rehabilitation program is the most appropriate referral for a client with severe hypertension who requires detoxification for alcohol use disorder. Residential programs provide 24-hour medical supervision, structured detoxification, and comprehensive support. This level of care is necessary to manage both the medical complications of hypertension and the risks associated with alcohol withdrawal, such as seizures or delirium tremens.

Choice B reason: Intensive outpatient therapy is beneficial for clients who are medically stable and can manage withdrawal symptoms safely outside of a hospital or residential setting. However, this client has severe hypertension and requires detoxification, which necessitates closer monitoring than outpatient care can provide.

Choice C reason: Alcoholics Anonymous is a peer-support group that provides ongoing recovery support but does not offer medical detoxification or structured treatment. While AA can be valuable after stabilization, it is not appropriate as the initial referral for a client requiring medical detox.

Choice D reason: A halfway house provides transitional living arrangements for individuals recovering from substance use disorders. It is useful after detoxification and initial treatment but does not provide the medical supervision or detox services needed at this stage.

Choice A reason: Referring the client to the provider dismisses the client’s immediate concern and does not foster therapeutic communication. While providers can give medical details, the nurse’s role is to explore feelings and provide support. This response blocks communication.

Choice B reason: Telling the client not to worry minimizes their concern and invalidates their feelings. Clients with anorexia nervosa often have significant anxiety about their health and body image. This response is non-therapeutic and does not encourage further discussion.

Choice C reason: Asking “Why” questions can make the client feel defensive and pressured to justify their feelings. Therapeutic communication avoids “Why” phrasing because it can hinder open dialogue.

Choice D reason: Reflecting the client’s concern by restating it in a supportive way acknowledges their fear and invites them to elaborate. This therapeutic response validates the client’s feelings and opens the door for further discussion about their health and emotional state.