Choice A rationale:

Asking the client about the lethality of their plan is the most appropriate action. This allows the nurse to assess the immediate risk to the client’s safety.

Choice B rationale:

Encouraging the client to focus on the positive aspects of life may be helpful in some situations, but it does not address the immediate safety concern.

Choice C rationale:

Reassuring the client that everything is going to work out may provide temporary relief, but it does not address the immediate safety concern.

Choice D rationale:

Allowing the client time alone to self-reflect is not appropriate in this situation as it could increase the risk of self-harm.

Choice A rationale:

Stress from a new job could indeed be a cause of a depressed mood. Changes in life circumstances, such as starting a new job, can be stressful and lead to feelings of depression.

Choice B rationale:

High blood pressure is not typically a direct cause of a depressed mood. It is a physical health condition that needs to be managed, but it does not directly cause depression.

Choice C rationale:

An elevated heart rate is not typically a direct cause of a depressed mood. It is a physical symptom that can be associated with many different conditions, but it does not directly cause depression.

Choice D rationale:

Renal dysfunction is not typically a direct cause of a depressed mood. It is a physical health condition that needs to be managed, but it does not directly cause depression.

Choice A rationale:

Stress from a new job could indeed be a cause of a depressed mood. Changes in life circumstances, such as starting a new job, can be stressful and lead to feelings of depression.

Choice B rationale:

High blood pressure is not typically a direct cause of a depressed mood. It is a physical health condition that needs to be managed, but it does not directly cause depression.

Choice C rationale:

An elevated heart rate is not typically a direct cause of a depressed mood. It is a physical symptom that can be associated with many different conditions, but it does not directly cause depression.

Choice D rationale:

Renal dysfunction is not typically a direct cause of a depressed mood. It is a physical health condition that needs to be managed, but it does not directly cause depression.

Choice A rationale:

Opiate withdrawal is a condition that occurs when a person stops using opiates after prolonged use. It is characterized by symptoms such as restlessness, muscle and bone pain, insomnia, diarrhea, vomiting, and cold flashes. The AIMS assessment is not typically used for this condition.

Choice B rationale:

Tardive dyskinesia is a movement disorder characterized by irregular, involuntary movements most commonly in areas of the face, around the eyes, and of the mouth, including the jaw, tongue, and lips. The AIMS assessment is a clinical outcome checklist completed by a healthcare provider to assess the presence and severity of abnormal movements of the face, limbs, and body in patients with tardive dyskinesia.

Choice C rationale:

Alcohol withdrawal is a condition that can occur when a person who has been drinking too much alcohol every day suddenly stops drinking alcohol. Symptoms can include tremors, anxiety, nausea and vomiting, headaches, increased heart rate, and seizures. The AIMS assessment is not typically used for this condition.

Choice D rationale:

Lithium toxicity, also known as lithium overdose, can occur if you take too much lithium, a mood-stabilizing medication. Symptoms can include hand tremor, increased thirst, increased urination, diarrhea, vomiting, weight gain, and impaired memory. The AIMS assessment is not typically used for this condition.

Choice A rationale:

Shakiness is a common symptom of panic level anxiety. It is a physical manifestation of the body’s fight-or-flight response being triggered, which can cause trembling or shaking.

Choice B rationale:

Depersonalization is a symptom of panic disorder, but it is not the most common or expected finding. It involves feeling detached or disconnected from oneself, observing oneself from an outside perspective, or experiencing a sense of unreality.

Choice C rationale:

Voice tremors could be a symptom of panic level anxiety as it can be a result of the increased adrenaline in the body. However, it is not the most common or expected finding.

Choice D rationale:

Poor concentration can be a symptom of panic level anxiety. However, it is not the most common or expected finding. During a panic attack, the person is likely to be focused on their physical symptoms and their fear of what might happen.

Choice A rationale:

If a client states that they do not want to live anymore and plans to end their life, the nurse should ask the client about the lethality of their plan. This can help the nurse assess the immediate risk and determine the appropriate level of intervention.

Choice B rationale:

While it’s important to encourage clients to focus on the positive aspects of life, this should not be the first response when a client expresses suicidal ideation. The priority is to assess the risk and ensure the client’s safety.

Choice C rationale:

Reassuring the client that everything is going to work out may seem helpful, but it can also minimize the client’s feelings and potentially make them feel misunderstood. The priority is to assess the risk and ensure the client’s safety.

Choice D rationale:

Allowing the client time alone to self-reflect is not the appropriate action when a client expresses suicidal ideation. The client should not be left alone, as they may be at risk of self-harm.

Choice A rationale:

A necklace is not a risk as it does not pose a threat to the client’s safety.

Choice B rationale:

Lace-up tennis shoes are allowed as they do not pose a risk to the client’s safety.

Choice C rationale:

Nylon socks are allowed as they do not pose a risk to the client’s safety.

Choice D rationale:

Cotton underwear is allowed as it does not pose a risk to the client’s safety.

Choice E rationale:

A glass-framed picture should be taken back home as it can be broken and potentially used to harm oneself.

Choice A rationale:

Families where caregivers have college degrees or higher are often more stable and provide a nurturing environment, which is a protective factor against adverse childhood experiences.

Choice B rationale:

Children who don’t feel close to their guardians and don’t feel like they can talk to them about their feelings are at a higher risk of developing mental health disorders.

Choice C rationale:

Families that include young caregivers or single parents often face more stress and instability, which can increase the risk of adverse childhood experiences.

Choice D rationale:

Families that are isolated from other people, such as extended family, friends, and neighbors, often lack social support, which can increase the risk of adverse childhood experiences.

Choice A rationale:

Physical harm is not a necessary condition for developing a trauma-related disorder. Emotional and psychological trauma can also lead to these disorders.

Choice B rationale:

Genetics can predispose individuals to trauma-related disorders, but it is not the sole cause. Environmental factors, such as experiencing or witnessing a traumatic event, play a significant role.

Choice C rationale:

Experiencing or witnessing a traumatic event can indeed result in developing a trauma-related disorder. This is because the event can cause significant emotional distress and impact the individual’s ability to cope.

Choice D rationale:

While chemical imbalances in the brain can be associated with trauma-related disorders, they are typically a result of the disorder rather than the cause.

Choice A rationale:

Adaptive vs. maladaptive refers to how well an individual’s behavior or response helps them cope with stressors. It’s the most relevant concept for understanding and delivering nursing care in this context.

Choice B rationale:

Justified vs. unjustified is not a relevant concept in this context as it pertains to moral or ethical judgments, not stress responses.

Choice C rationale:

Good vs. bad is also not relevant in this context as it’s a subjective judgment, not a measure of stress response.

Choice D rationale:

Right vs. wrong is not relevant in this context as it pertains to moral or ethical judgments, not stress responses.

Choice A rationale:

The Adaptive Phase is when the body first recognizes stress, but it has not yet started to respond.

Choice B rationale:

The Resistance Phase is when the body begins to respond to the stressor.

Choice C rationale:

The Exhaustion Phase is when the body has been responding to a stressor for an extended period and begins to lose the ability to combat the stressor, which could explain the recurring manifestations of influenza.

Choice D rationale:

The Alarm Phase is the initial phase of the GAS, but it does not explain the recurring manifestations of influenza.

Choice A rationale:

Avoiding foods that contain tyramine is important when taking monoamine oxidase inhibitors, not antipsychotics like clozapine.

Choice B rationale:

Limiting fluid intake is not typically necessary when taking antipsychotics.

Choice C rationale:

Medication adherence after the resolution of acute psychosis is crucial when taking antipsychotics to prevent relapse.

Choice D rationale:

Routine red blood cell count laboratory work is not typically necessary when taking antipsychotics like clozapine.

Choice A rationale:

A child’s perception of their parent being mean because they can’t have a dog does not qualify as an adverse childhood experience (ACE). ACEs are traumatic events that can have lasting, negative effects on health and well-being.

Choice B rationale:

Having a parent in prison is considered an ACE. This situation can cause significant stress and instability in a child’s life, potentially leading to long-term health and social issues.

Choice C rationale:

Failing a test, while potentially stressful, is not considered an ACE. It’s a common part of academic life and does not typically result in long-term trauma.

Choice D rationale:

Forgetting lunch at home is not considered an ACE. While it may be an inconvenience, it does not constitute a traumatic event.

Choice A rationale:

A vulnerability gene is a variant that increases the risk for the development of a specific mental illness. It does not guarantee the development of the illness, but it increases susceptibility.

Choice B rationale:

A vulnerability gene is not solely responsible for the development of a specific mental illness. Mental illnesses are typically the result of a combination of genetic, environmental, and psychological factors.

Choice C rationale:

A vulnerability gene does not determine an individual’s resilience to stress. Resilience is a complex trait influenced by multiple genes and environmental factors.

Choice D rationale:

A vulnerability gene does not determine an individual’s likelihood of recovering from mental illness. Recovery is influenced by a variety of factors, including treatment, support systems, and individual resilience.

Choice A rationale:

Schizophrenia is typically not diagnosed in school-age children. Symptoms may begin to appear in late adolescence, but diagnosis usually occurs in adulthood.

Choice B rationale:

Schizophrenia is not typically diagnosed in preschoolers. Symptoms of schizophrenia are rarely seen in children this young.

Choice C rationale:

Schizophrenia is most commonly diagnosed in young adulthood. This is when symptoms such as hallucinations, delusions, and disorganized thinking typically become apparent.

Choice D rationale:

While schizophrenia can be diagnosed in older adulthood, it is less common. Most individuals with schizophrenia are diagnosed earlier in life.

Choice A rationale:

This statement indicates restlessness, which is not typically associated with depression.

Choice B rationale:

This statement indicates insomnia, which is a common symptom of depression.

Choice C rationale:

High blood pressure is not a symptom of depression.

Choice D rationale:

Increased alertness and focus are not typical symptoms of depression.

Choice A rationale:

Valbenazine is a medication approved by the FDA for treating tardive dyskinesia.

Choice B rationale:

Diphenhydramine is an antihistamine and is not used to treat tardive dyskinesia.

Choice C rationale:

Naloxone is used to reverse opioid overdose, not tardive dyskinesia.

Choice D rationale:

Fluoxetine is an antidepressant and does not treat tardive dyskinesia.

Choice A rationale:

ECT does cause brief seizures, which is a correct understanding of the procedure.

Choice B rationale:

One ECT treatment is usually not enough to effectively treat depression.

Choice C rationale:

A pre-ECT workup is typically required before the procedure.

Choice D rationale:

Patients are usually required to fast before ECT due to the use of general anesthesia.

Choice A rationale:

The client’s statement about experiencing nightmares after a car crash 2 weeks ago is consistent with acute stress disorder, which can occur within 3 days to 1 month after exposure to a traumatic event.

Choice B rationale:

This statement suggests a condition known as post-traumatic stress disorder (PTSD), which is characterized by symptoms that last longer than 1 month and cause significant impairment or distress.

Choice C rationale:

Frequent flashbacks of childhood physical abuse also suggest PTSD, not acute stress disorder.

Choice D rationale:

The feeling of leaving one’s body when hearing people yelling or fighting is indicative of a dissociative disorder, not acute stress disorder.

Choice A rationale:

Blood pressure is a vital sign and does not indicate negative symptoms of schizophrenia.

Choice B rationale:

Lack of motivation is a negative symptom of schizophrenia, characterized by a decrease in the ability to initiate purposeful activities.

Choice C rationale:

Change in behavior can be seen in many conditions and is not specific to negative symptoms of schizophrenia.

Choice D rationale:

Lack of energy, or anhedonia, is a negative symptom of schizophrenia, reflecting the diminished ability to experience pleasure.

Choice E rationale:

Being withdrawn or isolative is a negative symptom of schizophrenia, indicating a lack of interest in social interactions.

Choice A rationale:

Blood pressure is a vital sign and does not indicate negative symptoms of schizophrenia.

Choice B rationale:

Lack of motivation is a negative symptom of schizophrenia, characterized by a decrease in the ability to initiate purposeful activities.

Choice C rationale:

Change in behavior can be seen in many conditions and is not specific to negative symptoms of schizophrenia.

Choice D rationale:

Lack of energy, or anhedonia, is a negative symptom of schizophrenia, reflecting the diminished ability to experience pleasure.

Choice E rationale:

Being withdrawn or isolative is a negative symptom of schizophrenia, indicating a lack of interest in social interactions. .

Choice A rationale:

Depersonalization is a symptom of PTSD, but it involves feeling detached from oneself, not reenacting traumatic events.

Choice B rationale:

Posttraumatic play is a common manifestation of PTSD in children. It involves the child reenacting the traumatic event, which can be seen in the child’s mimicking of shooting a gun.

Choice C rationale:

Omen formation is a belief that there were warning signs predicting the trauma. It’s not related to the child’s behavior.

Choice D rationale:

Time skewing involves a shift in the perception of time during the recall of the traumatic event. It’s not demonstrated in this scenario.

Choice A rationale:

While anyone can get cancer, it’s not specifically linked to schizophrenia.

Choice B rationale:

Osteoarthritis is a degenerative joint disease. It’s not a common comorbidity with schizophrenia.

Choice C rationale:

Alzheimer’s disease is a type of dementia. It’s not typically associated with schizophrenia.

Choice D rationale:

Diabetes mellitus is a common comorbidity with schizophrenia. Antipsychotic medications can increase the risk of developing type 2 diabetes.

Choice A rationale:

Mood stabilizers are used for bipolar disorder, not for symptoms like delusions and hallucinations.

Choice B rationale:

Benzodiazepines are used for anxiety and panic disorders. They don’t treat psychotic symptoms.

Choice C rationale:

Dopamine antagonists, or antipsychotics, are the primary treatment for schizophrenia. They can reduce delusions and hallucinations.

Choice D rationale:

SSRIs are used for depression and some anxiety disorders. They don’t treat psychotic symptoms.

Choice A rationale:

Ignoring the client’s lack of self-care is not therapeutic. It’s important to address hygiene issues with clients who have schizophrenia.

Choice B rationale:

This approach is confrontational and does not respect the client’s autonomy or dignity.

Choice C rationale:

This is the best choice because it respects the client’s autonomy and provides them with a choice, which can help motivate them to participate in self-care activities.

Choice D rationale:

This statement is judgmental and confrontational, which is not therapeutic.