Choice A Reason:

A child whose parents answer questions for the child may be a potential victim of abuse. This behavior can indicate that the parents are controlling the child's interactions and possibly hiding signs of abuse. Children who are victims of abuse often have their autonomy and voice suppressed by their abusers. This suppression can manifest in parents answering questions on behalf of the child to prevent the child from disclosing any information about the abuse. Additionally, this behavior can be a red flag for healthcare providers to investigate further and ensure the child's safety.

Choice B Reason:

A child who has frequent visitors is less likely to be a victim of abuse. Frequent visitors can indicate that the child has a strong support system and is socially active. Abusers often isolate their victims to maintain control and prevent them from seeking help. Therefore, a child with many visitors is less likely to be isolated and more likely to have opportunities to disclose any abuse if it were occurring.

Choice C Reason:

A child who has a BMI indicating obesity is not necessarily a potential victim of abuse. While obesity can be a concern for a child's health, it is not directly linked to abuse. Obesity can result from various factors, including genetics, diet, and lifestyle. It is important to address obesity from a health perspective, but it should not be immediately associated with abuse without other supporting evidence.

Choice D Reason:

A child who uses the call light frequently may be seeking attention or assistance, but this behavior alone does not indicate abuse. Frequent use of the call light can be due to various reasons, such as anxiety, discomfort, or a need for reassurance. While it is important to address the child's needs and understand the underlying reasons for their behavior, it does not specifically point to abuse.

Choice A Reason:

Meeting his daughter for dinner every week indicates that the client is maintaining social connections and engaging in regular activities. This behavior is generally considered healthy and adaptive, as it shows the client is seeking support and companionship, which are important aspects of coping with grief.

Choice B Reason:

Joining a bowling league 2 months ago suggests that the client is actively participating in social and recreational activities. This is a positive sign of adaptation and indicates that the client is finding ways to engage with others and enjoy life, which can be beneficial for mental health and well-being.

Choice C Reason:

Exercising at a local health facility 3 days each week demonstrates that the client is taking care of his physical health. Regular exercise is known to have numerous benefits, including reducing symptoms of depression and anxiety, improving mood, and enhancing overall well-being. This behavior is indicative of adaptive coping mechanisms.

Choice D Reason:

Keeping his partner's closet untouched since her death is a sign of maladaptive grief. This behavior suggests that the client is unable to move forward and is holding on to the past in a way that interferes with his ability to adapt to the loss. Maladaptive grief can manifest as an inability to accept the loss, persistent yearning for the deceased, and difficulty engaging in life without the deceased.

Choice A Reason:

The comment "I haven't gotten my period yet, and all my friends have theirs" reflects a common concern among adolescents regarding physical development and peer comparison. While this can cause anxiety, it is generally a normal part of adolescent development. The nurse can reassure the adolescent that the timing of puberty varies widely and that it is normal to develop at a different pace than peers.

Choice B Reason:

The concern about a pimple on the face, "There's a big pimple on my face, and I worry that everyone will notice it," is typical of adolescent worries about appearance and self-esteem. While it is important to address these concerns and provide support, it is not as urgent as addressing potential social isolation or mental health issues.

Choice C Reason:

The statement "My parents treat me like a baby sometimes" indicates a common struggle for independence among adolescents. This issue can be addressed through family counseling and communication strategies to help the adolescent and parents navigate this developmental stage. However, it does not indicate an immediate risk to the adolescent's well-being.

Choice D Reason:

The comment "None of the kids at this school like me, and I don't like them either" is the most concerning and should be the nurse's priority. This statement suggests social isolation and potential feelings of depression or low self-esteem. Social isolation can have significant negative impacts on an adolescent's mental health and development. It is crucial for the nurse to explore this further, provide support, and possibly refer the adolescent to a mental health professional.

Choice A Reason:

The statement "I have heard that abusers try to keep their partner isolated from others" is accurate. Abusers often isolate their victims to maintain control and prevent them from seeking help or support. This isolation can be physical, emotional, or social, and it is a common tactic used by abusers to exert power over their partners.

Choice B Reason:

The statement "I know that men who are abusers gain power through intimidation" is also correct. Abusers often use intimidation, threats, and fear to control their victims. This can include verbal threats, physical violence, and other forms of coercion. Intimidation is a key component of the power and control dynamics in abusive relationships.

Choice C Reason:

The statement "I have heard that abusers think of themselves as important and have high self-esteem" is incorrect and indicates a need for clarification. Research shows that many abusers actually have low self-esteem and feelings of inadequacy. They often use abusive behavior to compensate for their own insecurities and to feel a sense of power and control. Abusers may appear confident and self-assured, but this is often a facade to mask their underlying insecurities.

Choice D Reason:

The statement "I know that abusers lack social supports and social skills" is accurate. Many abusers have poor social skills and lack supportive relationships. This can contribute to their abusive behavior, as they may struggle with communication, conflict resolution, and forming healthy relationships. The lack of social support can also exacerbate feelings of isolation and frustration, leading to abusive behavior.

Choice A Reason:

The response "Your provider is very knowledgeable. If he prescribes chemotherapy, it's the best treatment for you" is authoritative and dismissive of the client's concerns. While it is important to trust medical professionals, this response does not address the client's feelings or provide an opportunity for open dialogue. It may make the client feel unheard and less likely to share their concerns in the future.

Choice B Reason:

The statement "Using nontraditional treatments is not a good idea. I'd rather you avoid that route" is also dismissive and does not foster a supportive environment. It outright rejects the client's interest in nontraditional treatments without exploring their reasons or providing education on the potential risks and benefits. This approach can lead to a breakdown in communication and trust between the nurse and the client.

Choice C Reason:

The response "Tell me more about your concerns about taking chemotherapy" is the most appropriate. It opens up a dialogue and allows the client to express their fears and concerns. This approach shows empathy and a willingness to understand the client's perspective. It also provides an opportunity for the nurse to educate the client about chemotherapy and address any misconceptions they may have. Engaging in a respectful and informative conversation can help the client make an informed decision about their treatment options.

Choice D Reason:

The statement "A lot of people think nontraditional treatments will work, and they find out too late that they made the wrong choice" is fear-inducing and dismissive. It does not respect the client's autonomy or provide a balanced view of nontraditional treatments. Instead, it uses scare tactics, which can further alienate the client and reduce their trust in the healthcare provider.

Choice A Reason:

The statement "You are feeling very depressed. I felt the same way when I decided to leave my husband" is non-therapeutic because it shifts the focus from the client to the nurse. This response demonstrates sympathy rather than empathy. Sympathy involves sharing one's own experiences and feelings, which can make the client feel unheard and invalidated. The nurse's role is to provide support and understanding without making the conversation about themselves.

Choice B Reason:

The statement "I can understand you are feeling depressed. It was a difficult decision. I'll sit with you" is more therapeutic. It acknowledges the client's feelings and offers support without shifting the focus to the nurse. This response shows empathy by validating the client's emotions and providing a comforting presence.

Choice C Reason:

The statement "You seem depressed. It was a difficult decision to make. Would you like to talk about it?" is therapeutic as it recognizes the client's feelings and invites them to express their thoughts and emotions. This approach encourages open communication and helps the client feel understood and supported.

Choice D Reason:

The statement "I know this is a difficult time for you. Would you like medication for anxiety?" is also therapeutic. It acknowledges the client's emotional state and offers a practical solution to help manage their anxiety. This response shows empathy and provides an option for addressing the client's immediate needs.

Choice A Reason:

Having the client join a therapy group immediately after admission is not the most therapeutic action for someone experiencing panic-level anxiety. Group settings can be overwhelming and may exacerbate the client's anxiety. It is important to first stabilize the client's anxiety before introducing them to group therapy.

Choice B Reason:

Remaining with the client in his room for a while is the most therapeutic action. This approach provides a calming presence and helps the client feel safe and supported. It allows the nurse to assess the client's anxiety level and offer immediate reassurance. Being present with the client can help reduce feelings of isolation and panic, creating a more stable environment for the client to begin to calm down.

Choice C Reason:

Suggesting that the client rest in bed may not be effective for someone with panic-level anxiety. While rest is important, the client may be too anxious to relax or sleep. Without addressing the immediate anxiety, simply suggesting rest may not provide the necessary support the client needs at that moment.

Choice D Reason:

Medicating the client with a sedative should be considered only after other non-pharmacological interventions have been attempted. While sedatives can help reduce anxiety, they should not be the first line of action. It is important to try to calm the client through therapeutic presence and reassurance before resorting to medication.

Choice A Reason:

Encouraging client input in the treatment plan is important for fostering a sense of autonomy and engagement in their care. However, it is not the highest priority when dealing with a client who has histrionic personality disorder. Clients with this disorder often exhibit dramatic and attention-seeking behaviors, which can interfere with their ability to participate effectively in treatment planning.

Choice B Reason:

Communicating with the client using concrete language is the highest priority. Clients with histrionic personality disorder may have difficulty with abstract thinking and may misinterpret vague or ambiguous statements. Using clear, concrete language helps ensure that the client understands the information being conveyed, which is crucial for effective communication and treatment adherence.

Choice C Reason:

Demonstrating assertive behavior is beneficial in managing clients with histrionic personality disorder, as it sets clear boundaries and models appropriate interpersonal interactions. However, it is not the highest priority compared to ensuring clear communication through concrete language.

Choice D Reason:

Promoting appropriate behavior during group therapy sessions is also important, as clients with histrionic personality disorder may exhibit disruptive behaviors in group settings. While this is a significant aspect of their care, it is secondary to the need for clear and concrete communication to ensure the client understands and adheres to their treatment plan.

Choice A Reason:

Marital skew refers to a situation where one partner in a marriage dominates the relationship, leading to an imbalance of power. This concept is not directly related to Bowen's theory of functional family interaction patterns. Instead, it is more associated with family dynamics that can lead to dysfunction rather than functionality.

Choice B Reason:

Sibling position is a concept within Bowen's family systems theory that suggests the order in which children are born in a family can influence their roles and behaviors within the family system. Bowen believed that understanding sibling positions can help in predicting certain family dynamics and interactions. For example, first-born children might take on more leadership roles, while later-born children might be more rebellious or independent. Recognizing these patterns can help in understanding and improving family interactions.

Choice C Reason:

Double-bind communication refers to a situation where a person receives two or more conflicting messages, with one message negating the other. This can create confusion and stress, as the person cannot resolve the contradiction. While this concept is important in understanding dysfunctional communication patterns, it is not a concept of functional family interaction in Bowen's theory.

Choice D Reason:

Pseudomutuality is a term used to describe a family dynamic where there is a false appearance of harmony and mutual understanding. This facade hides underlying conflicts and issues that are not addressed. Pseudomutuality is indicative of dysfunction rather than a functional family interaction pattern according to Bowen's theory.

Choice A Reason:

The statement "Your provider has explained the causes of schizophrenia. Why do you feel guilty about your daughter's diagnosis?" is not the most appropriate response. While it acknowledges the parents' feelings, it can come across as dismissive and may make the parents feel defensive. It does not provide a supportive environment for them to express their emotions and concerns.

Choice B Reason:

The statement "You said that you feel guilty about your daughter's diagnosis. Let's talk about what is causing you to feel this way." is the most appropriate response. It acknowledges the parents' feelings and invites them to share their thoughts and emotions. This approach fosters open communication and provides an opportunity for the nurse to offer support and reassurance. It helps the parents feel heard and understood, which is crucial in addressing their feelings of guilt.

Choice C Reason:

The statement "You should not feel guilty about your daughter's diagnosis. Schizophrenia is unpreventable." is factual but not therapeutic. It dismisses the parents' feelings of guilt without addressing the underlying emotions. While it is important to provide accurate information, it is equally important to validate the parents' feelings and offer emotional support.

Choice D Reason:

The statement "I'm sure your daughter's diagnosis is very difficult to deal with, but everything will be all right once she receives the proper treatment." is well-intentioned but overly reassuring. It may come across as minimizing the parents' concerns and does not provide an opportunity for them to express their feelings. It is important to balance reassurance with empathy and active listening.

Choice A Reason:

An overdose of disulfiram can cause symptoms such as nausea and vomiting, but it is less likely to be the cause in this scenario. Overdoses typically present with more severe symptoms, including seizures and coma in rare cases¹. The client's symptoms are more consistent with a disulfiram-alcohol reaction.

Choice B Reason:

An allergic response to disulfiram can cause symptoms such as rash, itching, and swelling, but severe nausea and vomiting are not typical allergic reactions². Allergic reactions would also likely present with other symptoms such as difficulty breathing or hives, which are not mentioned in this case.

Choice C Reason:

While nausea and vomiting can be common side effects of disulfiram, the severity described by the client suggests a more significant reaction. Common side effects are usually milder and do not typically cause the client to stop the medication abruptly.

Choice D Reason:

The most likely cause of the client's severe nausea and vomiting is the consumption of alcohol while taking disulfiram. Disulfiram works by inhibiting the enzyme acetaldehyde dehydrogenase, leading to an accumulation of acetaldehyde when alcohol is consumed. This results in unpleasant effects such as severe nausea, vomiting, headache, and flushing. The client's symptoms align with this reaction, making it the most probable cause.

Choice A Reason:

Monitoring the client closely to prevent self-mutilation is crucial for clients with certain personality disorders, such as borderline personality disorder, where self-harm is more prevalent. However, dependent personality disorder is characterized by a pervasive and excessive need to be taken care of, leading to submissive and clinging behavior. Self-mutilation is not a primary concern for this disorder.

Choice B Reason:

Setting limits to prevent exploitation of other clients is important in managing clients with antisocial personality disorder, who may manipulate or exploit others. Clients with dependent personality disorder are more likely to be overly reliant on others rather than exploit them. Therefore, this action is not the highest priority for this specific disorder.

Choice C Reason:

Giving positive feedback when the client is assertive with staff or clients is the most appropriate action. Clients with dependent personality disorder often struggle with making decisions and expressing their own needs due to their excessive reliance on others. Encouraging and reinforcing assertive behavior helps them develop independence and self-confidence, which are crucial for their treatment and overall well-being.

Choice D Reason:

Discouraging flamboyant or seductive behaviors is more relevant for clients with histrionic personality disorder, where attention-seeking and dramatic behaviors are common. Clients with dependent personality disorder do not typically exhibit these behaviors, so this action is not the highest priority.

Choice A Reason:

Recurrent thoughts of past trauma are more commonly associated with post-traumatic stress disorder (PTSD) rather than schizophrenia. While individuals with schizophrenia may have intrusive thoughts, these are typically related to delusions or hallucinations rather than past trauma.

Choice B Reason:

Inventing words that have no meaning, also known as neologisms, is a behavior associated with schizophrenia. This symptom reflects disorganized thinking, which is a hallmark of schizophrenia. Individuals with schizophrenia may create new words or use existing words in unusual ways, making their speech difficult to understand.

Choice C Reason:

Being preoccupied with folding clothes could be indicative of obsessive-compulsive disorder (OCD) or other anxiety-related conditions. While individuals with schizophrenia may exhibit repetitive behaviors, these are usually linked to their delusions or hallucinations rather than a preoccupation with specific tasks.

Choice D Reason:

Periods of elation with unusual talkativeness are more characteristic of bipolar disorder, particularly during manic episodes. Schizophrenia is typically associated with symptoms such as hallucinations, delusions, and disorganized thinking, rather than the mood swings seen in bipolar disorder.

Choice A Reason:

The death of a client's father two months ago, while significant, is not directly indicative of conduct disorder. Conduct disorder is characterized by a pattern of behavior that violates the rights of others or major societal norms. While a traumatic event like the death of a parent can impact a child's behavior, it is not a diagnostic criterion for conduct disorder.

Choice B Reason:

Experiencing frequent facial tics is more commonly associated with Tourette syndrome or other tic disorders, rather than conduct disorder. Conduct disorder involves behaviors such as aggression, theft, vandalism, and serious violations of rules, rather than physical tics.

Choice C Reason:

Adhering strictly to routines is a behavior more commonly associated with obsessive-compulsive disorder (OCD) or autism spectrum disorder (ASD). Conduct disorder is characterized by behaviors that are oppositional and defiant, rather than a need for strict routines.

Choice D Reason:

Being suspended from school several times in the past year is a behavior consistent with conduct disorder. This disorder is marked by a pattern of disruptive and rule-breaking behaviors, including aggression, deceitfulness, and serious violations of rules. Frequent suspensions from school indicate ongoing behavioral issues that align with the diagnostic criteria for conduct disorder.

Choice A Reason:

Medicating the patient with antipsychotics is not the first-line intervention for managing this behavior. Antipsychotics should be used cautiously and only when non-pharmacological interventions have failed or if the client poses a danger to themselves or others. Over-reliance on medication can lead to unnecessary side effects and does not address the underlying cause of the behavior.

Choice B Reason:

Assisting the client to the correct room is the most appropriate and immediate action. Clients with late-stage Alzheimer's disease often experience confusion and disorientation, which can lead to wandering and entering the wrong room. Gently guiding the client back to their own room helps to reduce their confusion and ensures the safety and comfort of both clients involved.

Choice C Reason:

Moving the client to a room at the end of the hall may not be effective in preventing future incidents and could increase the client's sense of isolation and confusion. It is more beneficial to address the immediate behavior and provide ongoing supervision and support to prevent wandering.

Choice D Reason:

Placing the client in restraints should be avoided unless absolutely necessary for the safety of the client or others. Restraints can cause physical and psychological harm and should only be used as a last resort. Non-restrictive interventions, such as redirection and supervision, are preferred.

Choice A Reason:

Exercising when feeling tense is an effective stress management technique. Physical activity helps to reduce stress hormones like cortisol and increases endorphins, which are natural mood lifters. Exercise can also improve sleep, which is often disrupted by stress, and provide a distraction from anxious thoughts.

Choice B Reason:

Fixing a pot of coffee when feeling anxious is the least effective stress management technique. Caffeine is a stimulant that can increase anxiety levels, cause jitteriness, and disrupt sleep patterns. For individuals who are already feeling anxious, consuming caffeine can exacerbate their symptoms and make it harder to manage stress effectively.

Choice C Reason:

Praying when beginning to breathe fast is a beneficial stress management technique for many people. Prayer and other forms of spiritual practice can provide a sense of calm, reduce stress, and offer emotional support. It can also help individuals feel more connected and less isolated during stressful times.

Choice D Reason:

Journaling when finding it difficult to talk is an effective way to manage stress. Writing down thoughts and feelings can help individuals process their emotions, gain insights into their stressors, and find solutions to their problems. Journaling can also serve as a therapeutic outlet for expressing feelings that might be hard to verbalize.

Choice A Reason:

Clients with severe intellectual disability typically require significant assistance with daily living activities. While they may be able to perform some basic self-care tasks with supervision, their ability to function independently is limited. They often need help with tasks such as dressing, bathing, and eating.

Choice B Reason:

Advanced speech development is not characteristic of severe intellectual disability. In fact, individuals with severe intellectual disability often have limited verbal communication skills. They may use single words, phrases, or gestures to communicate, and their speech development is generally delayed.

Choice C Reason:

Clients with severe intellectual disability often have psychomotor impairments. These can include difficulties with coordination, balance, and fine motor skills. Therefore, it is incorrect to state that their psychomotor skills are not affected.

Choice D Reason:

Communicating wants and needs by "acting out" behaviors is a common characteristic of severe intellectual disability. Due to limited verbal communication skills, individuals may express themselves through behaviors such as tantrums, aggression, or self-injury. These behaviors are often a way to communicate frustration, discomfort, or unmet needs.

Choice A Reason:

Hiring a house cleaner can be a positive step for a caregiver. It indicates that the partner is seeking help to manage household tasks, which can reduce stress and prevent burnout. This action shows that the partner is taking proactive measures to maintain their well-being while caring for the client.

Choice B Reason:

Placing locks at the top of the doors leading to the outside is a safety measure commonly used to prevent clients with Alzheimer's disease from wandering. This action demonstrates that the partner is taking appropriate steps to ensure the client's safety. It does not necessarily indicate caregiver role strain.

Choice C Reason:

Losing 25 lb in the past 3 months is a significant indicator of caregiver role strain. Rapid weight loss can be a sign of stress, depression, or neglecting one's own health due to the demands of caregiving. This observation suggests that the partner may be overwhelmed and struggling to cope with the caregiving responsibilities.

Choice D Reason:

Redirecting the client when they are frustrated is a common and effective technique used by caregivers to manage challenging behaviors in clients with Alzheimer's disease. This action shows that the partner is using appropriate strategies to support the client and does not indicate caregiver role strain.

Choice A Reason:

Warning the client that further disruptions will result in seclusion can be perceived as punitive and may escalate the client's behavior. While setting consequences is important, it should be done in a way that is therapeutic and supportive rather than threatening.

Choice B Reason:

Asking the client to recommend consequences for her disruptive behavior may not be effective during a manic episode. Clients experiencing mania often have impaired judgment and may not be able to provide appropriate or realistic consequences. It is more effective for the nurse to set clear and consistent limits.

Choice C Reason:

Setting limits on the client's behavior and being consistent in approach is the most appropriate action. Clients experiencing mania benefit from clear boundaries and consistent responses from staff. This helps to create a structured environment that can reduce anxiety and prevent further disruptive behavior. Consistency in approach also helps the client understand the expectations and consequences of their actions.

Choice D Reason:

Ignoring the client's behavior is not appropriate, even though it is consistent with her illness. Disruptive behavior can affect other clients and the overall environment of the unit. It is important to address the behavior in a therapeutic manner to maintain a safe and supportive environment for all clients.

Choice A Reason:

Impulsive behaviors are a hallmark of manic episodes in bipolar disorder. During mania, individuals often exhibit poor judgment and engage in risky activities without considering the consequences. This can include spending sprees, reckless driving, or making hasty decisions.

Choice B Reason:

Sleeping for long periods of time is more indicative of a depressive episode rather than a manic episode. During mania, individuals typically experience decreased need for sleep and may feel energized despite getting very little rest.

Choice C Reason:

Interacting with others in a flirtatious way is a common behavior during manic episodes. Individuals may exhibit increased sociability, hypersexuality, and inappropriate or provocative behavior. This heightened sociability and flirtatiousness are often out of character for the individual when they are not experiencing mania.

Choice D Reason:

Dressing in black or grey clothing is not specifically associated with manic behavior. While changes in appearance can occur during mood episodes, the color of clothing is not a reliable indicator of mania. Manic episodes are more characterized by behaviors and mood changes rather than specific clothing choices.

Choice E Reason:

Talking in rapid, continuous speech, also known as pressured speech, is a classic symptom of mania. Individuals may speak quickly, loudly, and incessantly, making it difficult for others to interrupt or follow the conversation. This symptom reflects the heightened energy and racing thoughts typical of manic episodes.

Choice A Reason:

Determining the cause of the client's anxiety is important for long-term management and treatment planning. Understanding the underlying factors contributing to the anxiety can help in developing effective interventions. However, in a crisis situation, this is not the highest priority. Immediate safety concerns take precedence over identifying the cause.

Choice B Reason:

Identifying the client's coping skills is valuable for helping the client manage anxiety in the long term. Knowing what coping mechanisms the client has can guide the nurse in providing appropriate support and interventions. However, during an acute crisis, the immediate focus should be on ensuring the client's safety and stabilizing their condition.

Choice C Reason:

Protecting the client from injury to himself is the highest priority in a crisis intervention for acute anxiety. Clients experiencing severe anxiety may be at risk of self-harm or other dangerous behaviors. Ensuring the client's physical safety is the first and foremost concern. Once the client is safe, other interventions can be implemented to address the anxiety and its underlying causes.

Choice D Reason:

Ensuring that the client feels safe is crucial in managing acute anxiety. Creating a safe and supportive environment can help reduce the client's anxiety levels. However, this action is secondary to protecting the client from immediate harm. Safety measures should be implemented first, followed by efforts to make the client feel secure and supported.

Choice A Reason:

Becoming lost in a usually familiar environment is a significant early warning sign of Alzheimer's disease. This symptom indicates spatial disorientation and memory loss, which are common in the early stages of the disease. Individuals may forget familiar routes or become confused about their location, even in places they know well.

Choice B Reason:

Difficulty performing familiar tasks is another early warning sign of Alzheimer's disease. This can include challenges with routine activities such as cooking, managing finances, or using household appliances. The inability to complete tasks that were once easy and familiar is a key indicator of cognitive decline.

Choice C Reason:

Losing sense of time is a common symptom in the early stages of Alzheimer's disease. Individuals may forget dates, seasons, or the passage of time. They might also have trouble understanding something if it is not happening immediately. This disorientation can lead to confusion and difficulty planning or following schedules.

Choice D Reason:

Misplacing car keys is a common occurrence and not necessarily an early warning sign of Alzheimer's disease. While everyone misplaces items occasionally, it becomes a concern when individuals consistently place items in unusual locations and cannot retrace their steps to find them. However, this alone is not a definitive sign of Alzheimer's.

Choice E Reason:

Problems with performing basic calculations are indicative of cognitive decline associated with Alzheimer's disease. Individuals may struggle with simple arithmetic, balancing a chequebook, or managing finances. This difficulty with numbers and calculations is a common early symptom of the disease.

Choice A Reason:

The response "What are the voices telling you to do?" is appropriate because it allows the nurse to assess the content of the hallucinations and determine if there is an immediate risk of harm to the client or others. This approach shows empathy and concern for the client's experience while gathering crucial information to ensure safety. Understanding the nature of the voices can help the nurse provide appropriate interventions and support.

Choice B Reason:

Telling the client "You need to tell the voices to leave you alone" is not an effective response. This statement can be dismissive and may not acknowledge the client's distress. Clients with schizophrenia may not have the ability to control their hallucinations, and this response does not provide the necessary support or validation of their experience.

Choice C Reason:

The statement "You need to understand that there are no voices" is dismissive and invalidates the client's experience. Clients with schizophrenia perceive their hallucinations as real, and telling them that the voices do not exist can increase their distress and mistrust. It is important to acknowledge the client's experience while providing reassurance and support.

Choice D Reason:

Asking "Why do you think you are hearing the voices?" may not be helpful in the moment of acute distress. This question can be confusing and does not address the client's immediate fear and anxiety. The priority should be to assess the content of the hallucinations and ensure the client's safety rather than exploring the reasons behind the hallucinations.

Choice A reason:

Primary prevention in community mental health is focused on reducing the incidence of mental disorders within the population. This proactive approach involves strategies and interventions designed to prevent the onset of mental health issues before they manifest. It includes enhancing individual resilience, fostering a supportive environment, and promoting mental well-being to lower the incidence and impact of mental health problems.

Choice B reason:

Services aimed at reducing the residual defects associated with severe and persistent mental illness fall under tertiary prevention. Tertiary prevention focuses on reducing the negative impact of an already established disease by restoring function and reducing disease-related complications.

Choice C reason:

Early identification of problems and prompt initiation of effective treatment are aspects of secondary prevention. Secondary prevention aims to reduce the impact of a disease that has already occurred, through early detection and appropriate treatment to halt or slow its progression.

Choice D reason:

Interventions aimed at minimizing early symptoms of psychiatric illness and directed toward reducing the prevalence and duration of the illness can be considered part of both secondary and tertiary prevention. These interventions work to alleviate the effects of an existing condition and prevent it from becoming more severe or prolonged.

Choice A reason:

Persecutory delusions involve the belief that one is going to be harmed, or that someone is conspiring against them. This type of delusion is characterized by feelings of being followed, spied on, poisoned, or tormented. The client's belief of engagement to the Prince of England does not reflect these themes.

Choice B reason:

Erotomanic delusions are characterized by the belief that another person, often of higher status, is in love with the individual. In this case, the client's claim of being engaged to the Prince of England fits the description of an erotomanic delusion. This type of delusion can lead to significant distress and may result in stalking or other unwanted behaviors towards the object of their delusion.

Choice C reason:

Somatic delusions are false beliefs about one's body or health. For example, a person may believe they have a terrible disease or that a part of their body is not functioning correctly. The client's statement does not indicate any concerns about their physical health or body, so it is not a somatic delusion.

Choice D reason:

Delusions of control involve the belief that one's thoughts, feelings, or actions are being controlled by external forces. This type of delusion might manifest as beliefs about being controlled by aliens or having one's thoughts broadcasted. The client's statement about being engaged does not suggest that they feel controlled by someone or something else.