Choice A rationale:

Focuses on the nurse's feelings rather than the client's needs. This response may make the client feel guilty or defensive, and it does not address the underlying cause of their anger or frustration.

Shuts down communication. Saying "That's a hurtful thing to say" can signal to the client that the nurse is not open to hearing their concerns, which can hinder the development of trust and rapport.

Fails to acknowledge the client's pain. The client is in a vulnerable position, experiencing both physical and emotional pain. This response does not recognize the validity of their experience, which can further alienate them.

Choice B rationale:

Invites the client to share their perspective. By saying "Tell me more about that," the nurse demonstrates a willingness to listen and understand the client's concerns. This can help to build trust and rapport, and it can provide valuable insights into the client's experience.

Promotes exploration of feelings. Allowing the client to express their feelings can help them to process their emotions and to feel more understood. This can lead to a greater sense of control and empowerment, which can be beneficial for their overall coping and healing.

Gathers information to tailor care. By listening to the client's concerns, the nurse can gain a better understanding of their specific needs and preferences. This information can then be used to adjust the plan of care to better meet the client's individual needs.

Choice C rationale:

Dismisses the client's feelings. Saying "Well, that's your opinion" minimizes the client's experience and sends the message that their feelings are not important. This can damage the therapeutic relationship and make the client feel even more isolated and unsupported.

Fails to address the underlying issue. This response does not attempt to explore the reasons for the client's anger or frustration, which means that the problem is likely to continue.

Choice D rationale:

Sounds accusatory and confrontational. Asking "Why would you say such a thing?" can put the client on the defensive and make them feel like they have to justify their feelings. This can hinder open communication and make it more difficult to address the root of the problem.

May make the client feel judged or criticized. This response can come across as judgmental and uncaring, which can further alienate the client and damage the therapeutic relationship.

Choice A rationale:

Anger is a common and expected response to trauma, including sexual assault. It can stem from various sources, including:

Feelings of violation and powerlessness: Survivors may feel intense anger towards the perpetrator for taking control of their bodies and lives.

Betrayal: If the assault was committed by someone they knew or trusted, survivors may feel intense anger towards that person for breaking their trust.

Frustration and injustice: Survivors may feel angry at the injustice of the situation, the lack of control they had, and the ongoing impact of the trauma.

Difficulty processing other emotions: Anger can sometimes mask other emotions that are difficult to deal with, such as fear, sadness, or guilt.

Anger can manifest in various ways, including:

Irritability and outbursts: Survivors may have a short temper, snap at others easily, or have difficulty controlling their anger. Aggression: In some cases, anger can lead to physical or verbal aggression towards others or self-harming behaviors.

Withdrawal and isolation: Some survivors may withdraw from social interactions and relationships to avoid potential triggers for their anger.

Substance abuse: Some survivors may turn to alcohol or drugs to numb their feelings or cope with their anger.

Choice B rationale:

Sleeping 12 hours or more each day can be a symptom of PTSD, but it is not a specific indicator of anger. It can also be a sign of depression, anxiety, or hypersomnia, a sleep disorder characterized by excessive daytime sleepiness.

Choice C rationale:

PTSD can sometimes lead to an increased sense of detachment from others, rather than attachment. Survivors may feel emotionally numb, have difficulty trusting others, or withdraw from relationships.

Choice D rationale:

While some survivors of sexual assault may feel a need to talk about the event, it is not a universal symptom of PTSD. Some survivors may avoid talking about the event altogether due to the distress it causes.

Choice B rationale:

Schizophrenia is a severe mental illness that is characterized by disturbances in thought, perception, emotion, and behavior. It is associated with an increased risk of suicide, with estimates suggesting that up to 10% of individuals with schizophrenia will die by suicide.

Several factors contribute to the increased risk of suicide in individuals with schizophrenia, including:

Hopelessness and despair: Individuals with schizophrenia often experience profound feelings of hopelessness and despair, which can lead to suicidal thoughts and behaviors.

Psychotic symptoms: Psychotic symptoms, such as delusions and hallucinations, can also contribute to suicide risk. For example, an individual with schizophrenia may experience auditory hallucinations that command them to harm themselves.

Impaired judgment: Schizophrenia can impair an individual's judgment and decision-making abilities, which can make it more difficult for them to resist suicidal urges.

Social isolation: Individuals with schizophrenia often experience social isolation, which can further increase their risk of suicide.

Comorbidity with other mental disorders: Schizophrenia is often comorbid with other mental disorders, such as depression and anxiety, which can also increase suicide risk.

Substance abuse: Substance abuse is a common problem among individuals with schizophrenia, and it can further increase suicide risk.

Choice C rationale:

Alcohol use disorder is a chronic, relapsing brain disease characterized by compulsive alcohol use, despite harmful consequences. It is a significant risk factor for suicide, with studies suggesting that individuals with alcohol use disorder are 10-14 times more likely to die by suicide than the general population.

Several factors contribute to the increased risk of suicide in individuals with alcohol use disorder, including: Depression: Alcohol use disorder is often comorbid with depression, which is a major risk factor for suicide. Impulsivity: Alcohol can impair judgment and increase impulsivity, which can lead to suicidal behaviors.

Social isolation: Alcohol use disorder can lead to social isolation, which can increase suicide risk.

Access to lethal means: Individuals with alcohol use disorder may have access to lethal means, such as firearms, which can increase the risk of suicide completion.

Choice D rationale:

Substance use disorder is a chronic, relapsing brain disease characterized by compulsive drug use, despite harmful consequences. It is a significant risk factor for suicide, with studies suggesting that individuals with substance use disorder are 6-12 times more likely to die by suicide than the general population.

Several factors contribute to the increased risk of suicide in individuals with substance use disorder, including: Depression: Substance use disorder is often comorbid with depression, which is a major risk factor for suicide. Impulsivity: Substance use can impair judgment and increase impulsivity, which can lead to suicidal behaviors.

Hopelessness: Individuals with substance use disorder may experience feelings of hopelessness and despair, which can increase suicide risk.

Social isolation: Substance use disorder can lead to social isolation, which can increase suicide risk.

Access to lethal means: Individuals with substance use disorder may have access to lethal means, such as firearms, which can increase the risk of suicide completion.

Choice F rationale:

Age greater than 65 years old is a risk factor for suicide. Suicide rates are highest among older adults, particularly white men over the age of 85.

Several factors contribute to the increased risk of suicide in older adults, including:

Chronic health conditions: Older adults are more likely to experience chronic health conditions, such as pain, disability, and cognitive decline, which can increase suicide risk.

Social isolation: Older adults are more likely to experience social isolation due to factors such as retirement, loss of loved ones, and decreased mobility.

Loss of independence: Older adults may experience a loss of independence due to physical and cognitive decline, which can contribute to suicide risk.

Access to lethal means: Older adults may have access to lethal means, such as firearms or medications, which can increase the risk of suicide completion.

Choice A rationale:

Personality disorders are not typically considered to be comorbidities of eating disorders. While some personality traits, such as perfectionism and obsessiveness, may be more common in individuals with eating disorders, these traits do not necessarily

constitute a personality disorder. Additionally, the presence of a personality disorder does not typically increase the risk of developing an eating disorder.

Choice B rationale:

Depression is one of the most common comorbidities associated with eating disorders. Studies have shown that up to 50% of individuals with eating disorders also experience depression. The relationship between eating disorders and depression is complex and bidirectional. Depression can contribute to the development of an eating disorder, and the behaviors associated with eating disorders can also worsen depression.

Choice C rationale:

Breathing-related sleep disorders, such as obstructive sleep apnea, are not typically associated with eating disorders. While some individuals with eating disorders may experience sleep disturbances, these disturbances are more likely to be related to other factors, such as anxiety or depression.

Choice D rationale:

Obsessive-compulsive disorder (OCD) is another common comorbidity of eating disorders. Studies have shown that up to 30% of individuals with eating disorders also have OCD. The symptoms of OCD, such as obsessive thoughts and compulsive behaviors, can overlap with the symptoms of eating disorders. For example, an individual with OCD may have obsessive thoughts about food and weight, and they may engage in compulsive behaviors related to eating, such as calorie counting or food restriction.

Choice E rationale:

Schizophrenia is not typically associated with eating disorders. While some individuals with schizophrenia may experience disturbances in eating behavior, these disturbances are more likely to be related to other symptoms of the disorder, such as delusions or hallucinations.

Choice F rationale:

Anxiety is another common comorbidity of eating disorders. Studies have shown that up to 60% of individuals with eating disorders also experience anxiety disorders. Anxiety can contribute to the development of an eating disorder, and the behaviors associated with eating disorders can also worsen anxiety.

Rationale:

Choice A is incorrect. Alprazolam does not have any known dietary interactions with aged cheeses. This information is specific to monoamine oxidase inhibitors (MAOIs), not benzodiazepines like alprazolam.

Choice B is incorrect. While some benzodiazepines can have side effects like drowsiness or dizziness that might indirectly affect blood pressure, alprazolam itself is not known to directly cause an increase in blood pressure.

Choice D is incorrect. Doubling the next dose of medication if a dose is missed is dangerous and can lead to overdose and increased risk of serious side effects. The client should be instructed to contact their doctor if they miss a dose.

Choice C is correct. Alprazolam is a pregnancy category D medication, meaning it has positive evidence of fetal risk. Studies have shown an increased risk of birth defects, including cleft lip and palate, in babies exposed to alprazolam during pregnancy. Therefore, it is crucial for women of childbearing age to use a reliable form of contraception while taking alprazolam to prevent unintended pregnancy and potential harm to the fetus.

Additional teaching points for the nurse:

The nurse should inform the client about the specific risks associated with alprazolam during pregnancy and the importance of discussing alternative treatment options if pregnancy is desired.

The nurse should emphasize the importance of using a reliable form of contraception that is effective both during and after treatment with alprazolam, as the medication can remain in the system for some time after the last dose.

The nurse should provide the client with resources on contraception and reproductive health, and encourage her to talk to her doctor about any s or concerns she may have.

Choice A rationale:

Anxiety reduction is the core motivation for ritualistic behaviors in OCD. Individuals with OCD experience intrusive, distressing thoughts (obsessions) that trigger intense anxiety. To neutralize this anxiety, they engage in repetitive behaviors (compulsions) that provide temporary relief.

The relief is often short-lived, leading to a cycle of obsessions and compulsions. This cycle can become debilitating and significantly impair daily functioning.

Research supports the anxiety-reduction model of OCD. Studies have shown that engaging in compulsions reduces anxiety in individuals with OCD, both subjectively and physiologically.

Neuroimaging studies have also demonstrated that ritualistic behaviors activate brain regions involved in anxiety and fear processing. This suggests that compulsions have a direct effect on the brain's anxiety circuitry.

Choice B rationale:

Sexual satisfaction is not a typical motivation for ritualistic behaviors in OCD. While some compulsions may have a sexual component (e.g., checking for arousal), the primary goal is to reduce anxiety, not to achieve sexual gratification.

Choice C rationale:

Feelings of shame may be associated with OCD, but they are not the primary driving force behind ritualistic behaviors. Shame often arises from the content of obsessions (e.g., thoughts about contamination, harm, or taboo subjects) or the perceived social stigma of OCD. However, the urge to perform compulsions stems from the need to alleviate anxiety, not to decrease shame.

Choice D rationale:

Boosting self-esteem is not a common motivation for ritualistic behaviors in OCD. In fact, many individuals with OCD experience low self-esteem due to the impact of the disorder on their lives. Compulsions may provide a temporary sense of control or mastery, but they do not typically lead to lasting improvements in self-esteem.

Choice A rationale:

It's okay to feel scared. Let's talk about what you are afraid of.

Acknowledges the client's feelings: This response directly acknowledges the client's fear and regret, which is a crucial first step in providing emotional support. It validates the client's experience and creates a safe space for open communication.

Invites the client to share: By inviting the client to talk about their fears, the nurse encourages open expression of emotions. This can help the client to process their feelings and gain a sense of control over their situation.

Promotes understanding: By actively listening to the client's concerns, the nurse can gain a better understanding of their individual needs and fears. This understanding can then guide the nurse in providing tailored support and interventions.

Facilitates coping: Talking about fears can help the client to identify and explore coping strategies. The nurse can assist in this process by offering suggestions, providing resources, and teaching relaxation techniques.

Strengthens the nurse-client relationship: By demonstrating empathy, active listening, and support, the nurse can foster a trusting relationship with the client. This relationship can provide a source of comfort and reassurance during a challenging time.

Choice B rationale:

Don't worry. The important thing is you have now quit smoking.

Dismisses the client's feelings: This response minimizes the client's fear and regret, which can be invalidating and hinder emotional expression.

Focuses on the past: While it's important to acknowledge the positive step of quitting smoking, this response shifts the focus away from the client's current emotional state and concerns about the upcoming surgery.

Offers false reassurance: Telling the client not to worry can be unrealistic and unhelpful, as it doesn't address the underlying fears.

Choice C rationale:

Your doctor is a great surgeon. You will be fine.

Provides premature reassurance: While it's appropriate to express confidence in the medical team, this response may not fully address the client's emotional needs. It can also inadvertently downplay the seriousness of the surgery and potential risks.

Shifts focus away from the client: This response focuses on the surgeon's skills rather than the client's feelings and concerns.

Choice D rationale:

I understand your fears. I was a smoker also.

May be perceived as self-focused: While sharing a personal experience can sometimes build rapport, it's important to ensure the focus remains on the client's needs and experiences. This response could inadvertently shift the attention to the nurse's own story.

Does not directly address the client's fears: While expressing understanding can be helpful, it's important to follow up with s and encouragement to explore the client's specific concerns.

Choice A rationale:

Protecting the client from injury is the highest priority nursing action in this scenario. Here's a detailed rationale explaining the importance of this action:

Choice A rationale:

Protecting the client from injury is the highest priority nursing action in this scenario. Here's a detailed rationale explaining the importance of this action:

1. Imminent Risk of Harm:

Acute anxiety can significantly impair judgment and impulse control, escalating the risk of self-harm or harm to others. It's crucial to prevent any actions that could result in physical injury, even if unintended.

2. Physiological Manifestations:

Anxiety can trigger physiological responses that heighten the potential for harm, such as: Increased heart rate and blood pressure

Hyperventilation Diaphoresis

Agitation and restlessness Dissociation

These physiological changes can contribute to accidents, falls, or other injuries.

3. Impaired Decision-Making:

Acute anxiety often clouds rational thinking and decision-making abilities.

Individuals may engage in behaviors they wouldn't consider in a calmer state, such as running away, lashing out, or attempting self-harm.

The nurse's role is to safeguard the client from potential consequences of these impulsive actions.

4. Establishing Safety as a Foundation for Care:

Ensuring physical safety creates a necessary foundation for subsequent interventions.

Once safety is established, the nurse can proceed with assessing coping skills, identifying anxiety triggers, and implementing therapeutic strategies.

5. Protecting Others:

In rare cases, acute anxiety can manifest in aggression towards others.

The nurse must protect not only the client but also other individuals who may be at risk.

6. Ethical and Legal Obligations:

Nurses have a professional duty to protect clients from harm, upholding ethical principles and legal standards of care.

7. Preventing Trauma:

Physical injuries sustained during a crisis can exacerbate anxiety and complicate recovery. Proactive safety measures aim to prevent further trauma and promote healing.

I'll provide detailed rationales for the other choices in separate messages to ensure clarity and comprehensiveness.

Choice B rationale:

Male gender is a significant risk factor for suicide. Men are more likely to die by suicide than women, with rates being approximately 3.5 times higher in men than women in the United States.

Several factors contribute to this increased risk:

Men are less likely to seek help for mental health issues. This may be due to societal expectations of masculinity, which often discourage men from expressing emotions or seeking help for emotional distress.

Men are more likely to use more lethal means of suicide. For example, men are more likely to use firearms, which have a higher fatality rate than other methods such as poisoning or cutting.

Men may be more likely to experience social isolation and loneliness. These factors can increase the risk of suicide, as they can lead to feelings of hopelessness and despair.

Men may be more likely to experience substance abuse problems. Substance abuse can increase the risk of suicide, as it can impair judgment and impulse control, and can also lead to feelings of hopelessness and despair.

Choice C rationale:

Recent marriage is not a risk factor for suicide. In fact, some studies have shown that marriage may have a protective effect against suicide.

However, it's important to note that relationship problems, including separation, divorce, or domestic violence, can be significant risk factors for suicide.

Choice D rationale:

Age greater than 55 is a risk factor for suicide. Suicide rates are highest among older adults, particularly among men aged 85 and older.

Several factors contribute to this increased risk:

Older adults are more likely to experience chronic health conditions and pain. These conditions can lead to feelings of hopelessness and despair, and can also make it more difficult to cope with stress.

Older adults are more likely to experience social isolation and loneliness. These factors can increase the risk of suicide, as they can lead to feelings of hopelessness and despair.

Older adults are more likely to experience bereavement and loss. The loss of a spouse, family members, or friends can be a major stressor, and can increase the risk of suicide.

Choice E rationale:

Diagnosis of schizophrenia is a significant risk factor for suicide.

People with schizophrenia are approximately 10 times more likely to die by suicide than the general population. Several factors contribute to this increased risk:

Schizophrenia is a severe mental illness that can cause significant distress and impairment.

People with schizophrenia may experience hallucinations, delusions, and disorganized thinking. These symptoms can be very distressing and can lead to feelings of hopelessness and despair.

People with schizophrenia may also experience social isolation and stigma. These factors can further increase the risk of suicide.

Choice A is incorrect. A lithium level of 1.0 mEq/L is within the therapeutic range (0.8 - 1.3 mEq/L). Gastric lavage is only indicated for significantly elevated lithium levels (>2.0 mEq/L) or in cases of recent overdose.

Choice B is incorrect. While the lithium level is within the therapeutic range, it is crucial to assess for early signs of toxicity, especially since the client has only been taking the medication for 2 weeks. Lithium levels can fluctuate, and early intervention is important to prevent toxicity.

Choice D is incorrect. While checking the medication record is a good practice, it does not address the immediate concern of potential lithium toxicity based on the current level and timeframe of medication use. Assessing for early symptoms is the appropriate next step.

Detailed rationale for each choice:

Choice A: Gastric lavage is a drastic and invasive procedure with potential complications. It is reserved for life- threatening situations with significantly elevated lithium levels (>2.0 mEq/L) or recent overdose. In this case, the client's lithium level is within the therapeutic range and there is no indication of recent overdose. Therefore, gastric lavage is not warranted.

Choice B: While administering the medication might seem appropriate because the lithium level is within the therapeutic range, it's crucial to consider the context. The client is new to lithium therapy (2 weeks), and early

manifestations of toxicity can occur even within the therapeutic range. Additionally, lithium levels can fluctuate, and administering the next dose without assessing for potential toxicity could put the client at risk. Therefore, holding the medication and assessing for early symptoms is the safer and more prudent approach.

Choice C: This is the correct choice. Holding the medication allows for a thorough assessment of the client for early signs of lithium toxicity, such as tremors, nausea, diarrhea, polyuria, and polydipsia. These symptoms can occur even with lithium levels within the therapeutic range, especially in the initial stages of treatment. By holding the medication and assessing the client, the nurse can determine if it is safe to resume therapy or if further interventions are needed.

Choice D: While verifying medication adherence is essential for managing any medication regimen, it does not address the immediate concern of potential lithium toxicity based on the current level and timeframe of medication use. Assessing for early symptoms is the crucial next step before considering medication adherence as a potential contributing factor.

In conclusion, holding the medication and assessing for early manifestations of toxicity is the most appropriate action for the nurse to take in this situation. This approach prioritizes the client's safety and allows for informed decision- making regarding the continuation of lithium therapy.

Monitoring the client's weight daily is essential for several reasons:

Tracking Progress: It provides objective data to track the client's progress toward weight gain and recovery. This information is crucial for adjusting treatment plans as needed.

Early Intervention: Daily weighing can help identify any early signs of weight loss or stagnation, allowing for prompt intervention to prevent relapse.

Accountability: Knowing that their weight is being monitored can serve as a motivation for the client to adhere to their meal plan and avoid engaging in disordered eating behaviors.

Medical Monitoring: Weight is a vital sign that reflects overall health status. In anorexia nervosa, weight loss can lead to severe medical complications, including electrolyte imbalances, cardiac arrhythmias, osteoporosis, and organ failure. Daily monitoring helps identify and address these risks promptly.

Rationale for Choice C:

Allowing the client to choose the meals she will eat can promote a sense of control and autonomy, which can be beneficial in the recovery process.

Reduced Anxiety: Individuals with anorexia often experience intense anxiety surrounding food and mealtimes. Providing choices can help alleviate some of this anxiety and make mealtimes less stressful.

Increased Engagement: When clients feel like they have a say in their food choices, they may be more likely to engage in the meal plan and consume adequate calories.

Building Trust: Allowing choices demonstrates respect for the client's preferences and can help build trust between the nurse and the client, which is essential for therapeutic progress.

Rationale for Choice E:

Providing the client with small meals frequently can help address the following challenges:

Reduced Appetite: Individuals with anorexia often experience a decreased appetite and early satiety. Smaller, more frequent meals are often better tolerated than larger, less frequent ones.

Fear of Overeating: Smaller meals can help mitigate the fear of overeating, which is a common concern in anorexia.

Maintaining Energy Levels: Frequent meals help maintain stable blood sugar levels and prevent energy crashes, which can contribute to fatigue, irritability, and difficulty concentrating.

Rationale for Choices B and D:

These choices are not appropriate for the following reasons:

Choice B: Allowing the client to choose the meals she will eat could potentially lead to inadequate calorie intake or unhealthy food choices that could hinder weight gain and recovery.

Choice D: Staying with the client during meals and for 2 hours after meals could create a sense of surveillance and control, which could increase anxiety and resistance to treatment. It could also interfere with the client's ability to develop normal eating patterns and coping mechanisms.

Choice A rationale:

1. Understanding OCD:

OCD is a chronic mental health condition characterized by intrusive thoughts (obsessions) and repetitive behaviors (compulsions).

Individuals with OCD feel compelled to perform rituals to relieve anxiety or prevent perceived harm, even if they recognize the behaviors as excessive or irrational.

Rituals can consume significant time and interfere with daily functioning.

2. Rationale for Choice A:

Acknowledges the client's needs: Planning for rituals demonstrates understanding and acceptance of the client's experience, fostering trust and rapport.

Reduces anxiety: Allowing time for rituals can temporarily reduce anxiety, making the client more receptive to other interventions.

Gradual approach: It's a stepping stone towards Exposure and Response Prevention (ERP), the gold-standard treatment for OCD.

Enhances control: Scheduling rituals can help the client feel more in control, reducing the urge to engage in them compulsively.

3. Addressing potential concerns:

Reinforcing rituals: While there's a possibility of temporarily reinforcing rituals, it's a necessary first step to build trust and engagement in therapy.

Interfering with treatment: Scheduling rituals is a part of a comprehensive treatment plan that includes ERP and other therapies to address the underlying causes of OCD.

4. Importance of individualized care:

The specific approach to planning for rituals should be tailored to the client's unique needs, preferences, and severity of symptoms.

Collaboration with the client is essential to ensure their active participation in treatment. I'll now address the rationales for the incorrect choices:

Choice B rationale:

Setting strict limits on behaviors can be counterproductive: Triggers anxiety and distress

Impedes trust and therapeutic alliance Diminishes sense of control

Heightens resistance to treatment

Choice C rationale:

Confronting the client about the senselessness of rituals is ineffective and potentially harmful: Exacerbates anxiety and shame

Alienates the client

Disregards the involuntary nature of OCD Undermines motivation for treatment Choice D rationale:

Isolating the client is unethical and detrimental:

Increases distress and loneliness Impedes therapeutic interactions Reinforces negative self-perceptions

Lacks evidence of efficacy in OCD treatment

Choice A rationale:

This response indicates anger, not denial. The client is expressing anger towards the doctor and their perceived lack of competence. While anger can be a component of the grief process, it does not specifically align with the denial phase, which is characterized by a refusal to accept the reality of a situation.

Choice B rationale:

This response indicates fatigue or depression, not denial. The client is acknowledging their physical and emotional state but is not expressing disbelief or refusal to accept their diagnosis.

Choice C rationale:

This response clearly demonstrates denial. The client is minimizing the severity of their diagnosis and attributing the doctor's statements to an ulterior motive. This is a classic example of denial, as it involves a distortion of reality to avoid facing a painful truth.

Choice D rationale:

This response indicates acceptance, not denial. The client is acknowledging the reality of their situation and expressing gratitude for the care they have received.

Rationale for Choice A:

Pacing can be a physical manifestation of anxiety. It allows individuals to release some of the nervous energy that builds up during anxious moments. Restricting this behavior can potentially escalate anxiety.

Walking with the client can provide a sense of safety and support. It demonstrates to the client that they are not alone in their anxiety and that the nurse is there to help them.

Gradually slowing the pace of the walk can help to regulate the client's breathing and heart rate. This can have a calming effect on both the body and mind.

Walking can also be a form of distraction. It can help to take the client's mind off of their worries and focus on the present moment.

Walking can help to release endorphins, which have mood-boosting effects. This can help to counteract some of the negative emotions associated with anxiety.

Rationale for Choice B:

Escorting the client to their room may be perceived as restrictive and controlling. This could potentially increase the client's anxiety.

Removing the client from the public area of the unit may isolate them from other people and activities. This could make them feel more alone and anxious.

Rationale for Choice C:

Allowing the client to pace alone may not be safe. The client could potentially become agitated or injure themselves.

Pacing alone does not provide the client with any support or guidance. This could make it more difficult for them to manage their anxiety.

Rationale for Choice D:

Instructing the client to sit down and stop pacing may be perceived as dismissive and unhelpful. It does not address the underlying causes of the client's anxiety.

Forcing the client to stop pacing could potentially escalate their anxiety. This could lead to agitation, aggression, or other negative behaviors.

Choice A rationale:

Dismissive and unsupportive: This response discounts the client's son's feelings of guilt and obligation toward their parent. It also implies that the client's son's presence is not valuable, which could further increase their distress.

Undermines the client's son's role as a caregiver: It suggests that the client's son has no responsibilities or ability to contribute to their parent's care, which could diminish their sense of agency and potentially lead to resentment or regret.

Fails to address the underlying emotions: It does not acknowledge the client's son's internal conflict and emotional turmoil, which is essential for providing effective support.

Choice C rationale:

Offers a practical solution, but may not address the core issue: While calling the children could provide temporary reassurance, it may not fully alleviate the client's son's feelings of guilt or anxiety about leaving their parent.

May not be feasible or sufficient: The client's son may need more than a phone call to feel comfortable leaving, and they may not be able to reach their children immediately.

Could be perceived as dismissive: It could suggest that the nurse is minimizing the client's son's concerns and not fully understanding their emotional needs.

Choice D rationale:

Reassuring, but may not address the client's son's guilt: While it provides assurance about the client's care, it does not directly acknowledge or validate the client's son's feelings of guilt or obligation.

Focuses on the client's care, but not the client's son's needs: It prioritizes the physical care of the client, but may overlook the emotional needs of the client's son, who is also a primary stakeholder in the situation.

May not be enough to alleviate the client's son's concerns: The client's son may still feel responsible for their parent's well- being, even with reassurance from the nurse.

Choice B rationale:

Empathetic and validates the client's son's feelings: It directly acknowledges the client's son's conflicting emotions and demonstrates understanding of their difficult situation.

Promotes self-reflection and exploration: It encourages the client's son to further express their feelings and explore their options, which can lead to greater clarity and self-awareness.

Facilitates decision-making: It helps the client's son to weigh their priorities and make a decision that aligns with their values and responsibilities, ultimately empowering them to take action.

Strengthens the therapeutic relationship: It demonstrates the nurse's ability to connect with the client's son on an emotional level, building trust and rapport.

Choice A rationale:

Intrusive and judgmental: Asking "Why did you wear clean clothes and comb your hair today?" directly challenges the client's behavior and implies that she needs to justify her actions. This can make the client feel defensive and less likely to open up.

Focuses on the past: The directs attention to the client's previous lack of self-care, which can reinforce negative feelings and discourage progress.

Assumes motivation: It presumes that the client made a conscious decision to change her appearance based on a specific reason, which may not be accurate and can invalidate her experience.

Choice B rationale:

Presumptuous and premature: Concluding that "Your mood must be lifting because you have on clean clothes and have combed your hair" makes assumptions about the client's internal state without proper assessment.

Oversimplifies depression: It suggests that improvements in self-care directly equate to mood improvement, which disregards the complexity of depression and its varied manifestations.

Can create pressure: The statement can inadvertently pressure the client to feel or act a certain way to meet the nurse's expectations, hindering genuine progress.

Choice D rationale:

Paternalistic and condescending: Expressing "Oh, I'm so pleased that you finally put on clean clothes" implies that the nurse has been waiting for or expecting this change, placing the nurse in a position of authority and potentially undermining the client's autonomy.

Focuses on the nurse's feelings: The statement centers on the nurse's approval rather than acknowledging the client's efforts and perspective.

Can reinforce dependency: It can foster a dynamic where the client seeks external validation for her actions, rather than developing internal motivation for self-care.

Choice C rationale:

Observational and non-judgmental: The statement "I see that you have on clean clothes and have combed your hair" simply acknowledges the client's actions without imposing any interpretation or judgment.

Invites conversation: It provides an opportunity for the client to elaborate on her choices if she feels comfortable, promoting autonomy and self-expression.

Validates effort: It subtly recognizes the client's efforts without explicitly praising or criticizing, fostering a sense of self- efficacy and encouraging continued self-care.

Demonstrates active listening: It shows that the nurse has been paying attention to the client's progress, which can strengthen the therapeutic relationship and build trust.

Choice A rationale:

Antipsychotic medications are a class of drugs commonly used to treat schizophrenia and other psychotic disorders. They work by blocking dopamine receptors in the brain. However, dopamine is also involved in motor control, and blocking its receptors can lead to extrapyramidal symptoms (EPS).

EPS are a group of movement disorders that can be caused by antipsychotic medications. They include: Akathisia: A feeling of restlessness and an inability to sit still.

Dystonia: Involuntary muscle contractions that can cause twisting or spasms.

Parkinsonism: Symptoms similar to Parkinson's disease, such as tremor, rigidity, and slowness of movement. Tardive dyskinesia: Involuntary, repetitive movements of the face, tongue, or other body parts.

The risk of developing EPS is higher with older antipsychotic medications, such as haloperidol and chlorpromazine. Newer antipsychotic medications, such as risperidone and olanzapine, are less likely to cause EPS, but they can still occur.

Clients who are taking antipsychotic medications should be monitored for EPS. If EPS develop, the medication may need to be changed or the dose reduced.

Choice B rationale:

Enzymes are not known to cause EPS. They are used to treat pancreatitis by helping the body to digest food.

Choice C rationale:

Insulin is not known to cause EPS. It is used to treat type 2 diabetes mellitus by helping the body to control blood sugar levels.

Choice D rationale:

Iron supplements are not known to cause EPS. They are often taken by pregnant women to prevent iron deficiency anemia.

Rationale:

Choice A: While social isolation can be a risk factor for suicide, spending time with close friends can actually be protective. This statement alone does not suggest an increased risk.

Choice B: Religious involvement and participation in religious activities can be protective factors against suicide by providing support, meaning, and a sense of belonging. This statement does not indicate a specific risk.

Choice C: Consistent, healthy sleep patterns are generally associated with positive mental health and are not indicative of suicidal ideation. This statement does not raise concerns for suicide risk.

Choice D: Exposure to suicide, particularly within one's social circle or among individuals one admires, is a significant risk factor for suicide due to the phenomenon of "social contagion." The recent suicide of the adolescent's favorite actor increases his vulnerability and necessitates immediate assessment and intervention.

Social contagion refers to the tendency for suicidal behaviors to spread within a community or group, particularly among adolescents and young adults. Exposure to a suicide can trigger suicidal thoughts and feelings in vulnerable individuals, especially if they identify with the deceased or perceive the suicide as a viable coping mechanism.

The adolescent's age (15 years) is also a crucial factor. Adolescence is a period of heightened emotional vulnerability and increased risk for suicidal ideation and behavior due to various developmental and psychosocial challenges.

The father's concern suggests that the adolescent may be exhibiting other concerning behaviors or changes in mood or behavior. The nurse should gather more information and conduct a comprehensive suicide risk assessment to determine the level of risk and implement appropriate interventions.

Additional considerations:

The nurse should inquire about the nature of the adolescent's relationship with the deceased actor, his emotional state since the suicide, and any other potential stressors or vulnerabilities he may be facing.

The nurse should involve the parents in the assessment and intervention process, providing them with education and resources on suicide prevention and support.

If the assessment indicates a high risk of suicide, the nurse should immediately refer the adolescent to a mental health professional or emergency department for further evaluation and treatment.

Remember: Suicide is a serious public health issue, and early identification and intervention are crucial in preventing tragic outcomes. School nurses play a vital role in recognizing warning signs and providing timely support and resources to adolescents at risk.

Choice A: Lock the doors to the unit and secure windows so they cannot be opened: While removing potential means of self-harm from the environment is a safety precaution, it is not the most immediate or effective intervention for a client actively experiencing suicidal ideation who has refused a safety contract. Locking doors and windows may increase anxiety and feelings of entrapment, potentially exacerbating the client's distress and hindering open communication. Additionally, it may not address underlying emotional and psychological factors contributing to the suicidal thoughts.

Choice B: Remove any objects from the client's environment that could be used for self-harm: Similar to Choice A, removing potential means can be a helpful safety measure but should not be the primary intervention in this situation. It is important to recognize that clients can find alternative means if they are determined to self-harm, and focusing solely on environmental control can detract from addressing the root of the suicidal crisis.

Choice C: Assign a staff member to stay with the client at times: This option prioritizes the client's safety and emotional well-being by providing constant support and supervision. A dedicated staff member can:

Monitor the client's behavior and emotional state closely, potentially identifying early warning signs of impending self-harm.

Provide open and non-judgmental support, allowing the client to express their thoughts and feelings freely without fear of being alone with their distress.

Engage in therapeutic communication, helping the client explore alternative coping mechanisms and develop safety plans for managing suicidal urges.

Alert other healthcare professionals if the client's condition deteriorates or if there is any immediate risk of self- harm.

Offer a sense of security and reassurance, knowing someone is constantly available to listen and intervene if needed.

Choice D: Provide the client with plastic eating utensils for meals: While this precaution may reduce the risk of self- harm at mealtimes, it addresses a very specific concern and does not address the broader issue of the client's suicidal ideation. It is also important to consider that plastic utensils may not be effective in preventing self-harm if the client is determined and resourceful.

Therefore, assigning a staff member to stay with the client at all times is the most appropriate and immediate action to prioritize the client's safety and emotional well-being in this situation. This approach fosters open communication, provides continuous support, and allows for early intervention if necessary. While environmental controls and risk assessments can be valuable complementary strategies, they should not overshadow the importance of close human connection and emotional support in crisis situations.

Choice A rationale:

Hypervigilance: The client's statement "I check any room I enter because the enemy is still after me and could be hiding anywhere" indicates hypervigilance, a hallmark symptom of PTSD. Individuals with PTSD often feel constantly on edge, as if they are in danger, even when they are not in a threatening situation. They may scan their surroundings for potential threats, have difficulty relaxing, and be easily startled.

Persistent re-experiencing: The client's checking behavior suggests that they are persistently re-experiencing the traumatic event, as if it is happening again in the present moment. This re-experiencing can take various forms, including intrusive thoughts, nightmares, flashbacks, and intense emotional or physical reactions to reminders of the trauma.

Avoidance: The client's hypervigilance and checking behavior may also serve as a form of avoidance. By constantly scanning for threats, they may be attempting to avoid any reminders of the trauma that could trigger distressing memories or emotions.

Choice B rationale:

Grandiosity: While the client's statement about killing four enemy soldiers might suggest a sense of grandiosity, which can be associated with PTSD, it does not specifically indicate the presence of other core PTSD symptoms such as hypervigilance, avoidance, or re-experiencing. Grandiosity can also be a feature of other mental health conditions, such as bipolar disorder or narcissistic personality disorder.

Choice C rationale:

Nightmares: The client's statement about having nightmares of the wounded reaching out to them does suggest re- experiencing, a symptom of PTSD. However, nightmares alone are not sufficient to diagnose PTSD, as they can also occur in other conditions such as anxiety disorders or sleep disorders.

Choice D rationale:

Guilt and self-blame: The client's statement about their child's birth defect might suggest feelings of guilt or self-blame, which can be associated with PTSD. However, this statement does not directly indicate the presence of other core PTSD symptoms. Additionally, the client's belief about the cause of the birth defect may or may not be accurate, and further assessment would be needed to determine the presence of guilt or self-blame related to the trauma.

Choice A rationale:

While it's true that the nurse has released the client's information without their explicit consent, this action is justified under the duty to warn and protect.

This duty supersedes the general obligation to maintain confidentiality when there's a serious and imminent threat to identifiable individuals or the public.

In this case, the client's verbal threat to bomb a local church constitutes a credible and foreseeable risk of harm, necessitating the breach of confidentiality to protect potential victims.

Choice B rationale:

Although the nurse's actions may help to avoid malpractice charges by demonstrating responsible care and adherence to ethical obligations, this is not the primary reason for notifying the minister.

The primary goal is to avert harm and fulfill the duty to warn, not to shield oneself from legal liability.

Choice C rationale:

This is the correct answer. The nurse has acted in accordance with the duty to warn and protect, which is a legal and ethical obligation in healthcare.

This duty mandates that healthcare professionals take reasonable steps to warn potential victims and protect the public when a patient communicates a serious threat of harm.

Choice D rationale:

While confidentiality is a cornerstone of healthcare ethics, it's not absolute.

The duty to warn and protect allows for limited breaches of confidentiality when necessary to prevent serious harm, as in this case.

The nurse's actions align with ethical principles and legal requirements, even though they involve disclosing confidential information.

Choice A rationale:

Manifestations of seizure activity are not a common adverse effect of clonazepam. In fact, clonazepam is often used to treat seizures. It is a benzodiazepine that works by decreasing abnormal electrical activity in the brain.

While it is possible for clonazepam to worsen seizures in some individuals, this is not a typical response. Therefore, it is not the most important adverse effect for the nurse to monitor.

Choice B rationale:

Decreased urine output is not a known adverse effect of clonazepam.

Some medications can affect kidney function and urine output, but clonazepam is not one of them. Therefore, it is not necessary for the nurse to monitor urine output in a client taking clonazepam. Choice C rationale:

Inability to recall events, also known as amnesia, is a common adverse effect of clonazepam.

Clonazepam can impair short-term memory, making it difficult for people to remember things that happened recently.

This can be a significant problem for clients who need to be able to recall important information, such as instructions from their healthcare providers.

Therefore, it is important for the nurse to monitor clients taking clonazepam for signs of amnesia.

Choice D rationale:

An increase in white blood cell count is not a known adverse effect of clonazepam. In fact, clonazepam can sometimes cause a decrease in white blood cell count.

However, this is a rare side effect and is not typically something that the nurse would need to monitor.

Choice A rationale:

This response is dismissive of the client's concerns and does not acknowledge their feelings. It also implies that the client is not knowledgeable about their own condition. This could make the client feel defensive and less likely to share their concerns in the future.

It focuses on the medical facts of the diagnosis rather than addressing the client's emotional state. It may come across as patronizing or judgmental, further alienating the client.

Choice B rationale:

This response demonstrates active listening and empathy. It acknowledges the client's feelings and validates their concerns. This can help to build trust and rapport with the client.

It encourages the client to express their fears and worries, which can be therapeutic in itself.

It opens the door for further discussion about the client's concerns and provides an opportunity for the nurse to offer support and education.

Choice C rationale:

This response is reassuring, but it does not address the client's underlying concerns. It may also come across as dismissive or patronizing.

It relies solely on the medical chart to make a judgment about the client's concerns, without taking into account the client's own perspective.

It does not provide an opportunity for the client to express their fears and worries.

Choice D rationale:

This response is a deflection and does not provide the client with the support they need in the moment. It may also make the client feel like their concerns are not being taken seriously.

It shifts the responsibility for addressing the client's concerns to the provider, which may not be helpful if the client is already feeling anxious or uncertain.

Choice A: Giving opinion: While sharing your opinions might seem helpful, it can actually shut down communication and make the patient feel judged or invalidated. Therapeutic communication focuses on understanding the patient's perspective, not imposing your own views.

Choice B: Asking why: Asking "why" can often come across as accusatory or judgmental, putting the patient on the defensive and hindering open communication. Instead, use open-ended s or clarifying statements to encourage the patient to elaborate on their feelings and experiences.

Choice C: Silence: In some situations, silence can be a powerful tool. It can provide a safe space for the patient to process their emotions, gather their thoughts, or initiate conversation themselves. However, be sure to use silence actively, paying close attention to nonverbal cues and ensuring the patient feels comfortable with the pause.

Choice D: Change the subject: While there may be times when it's appropriate to redirect the conversation, abruptly changing the subject can leave the patient feeling unheard and dismissed. It's important to acknowledge the patient's concerns and validate their feelings before moving on to another topic.

Choice E: Reflecting: Reflecting involves rephrasing the patient's words or statements in a way that acknowledges and emphasizes their emotions and experiences. This helps the patient feel heard and understood, promoting trust and openness in the communication. For example, if a patient says "I feel so alone," you could reflect by saying "It sounds like you're feeling isolated and disconnected."

Choice F: Clarification: Clarifying statements are a helpful way to ensure you understand the patient correctly. This can involve repeating parts of what they said, summarizing their message, or asking for specific details. For example, if a patient says "I just can't take it anymore," you could clarify by saying "You mentioned you're feeling overwhelmed. Can you tell me more about what's been difficult for you?"

By utilizing techniques like silence, reflecting, and clarification, nurses can create a safe and supportive environment for their patients in the mental health unit, fostering therapeutic communication that promotes healing and recovery.