Correct answer: D) All of the above.

Rationale: Low self-esteem is a negative evaluation of one's self-worth, often associated with depression. Clients with low self-esteem may exhibit behaviors such as making negative statements about themselves, expressing dissatisfaction with their appearance and abilities, avoiding eye contact and speaking in a low voice, and having difficulty accepting compliments or praise.

Incorrect options:

A) The client frequently makes negative statements about themselves. - This is a correct indicator of low self-esteem, but not the only one.

B) The client expresses dissatisfaction with their appearance and abilities. - This is a correct indicator of low self-esteem, but not the only one.

C) The client avoids eye contact and speaks in a low voice. - This is a correct indicator of low self-esteem, but not the only one.

Correct answer: D) All of the above.

Rationale: Group therapy is a form of psychotherapy that involves one or more therapists working with several clients who share a common problem or goal. Group therapy can help clients with anxiety disorders by providing social support, education, coping skills, and exposure to feared situations. To facilitate effective communication and interaction among the group members, the nurse should use strategies such as establishing clear and consistent rules and expectations for the group, encouraging active participation and feedback from all group members, and using open-ended questions and reflective statements to elicit responses.

Incorrect options:

A) Establish clear and consistent rules and expectations for the group. - This is a correct strategy, but not the only one.

B) Encourage active participation and feedback from all group members. - This is a correct strategy, but not the only one.

C) Use open-ended questions and reflective statements to elicit responses. - This is a correct strategy, but not the only one.

Correct answer: D) "That must be very frightening for you. How can I help you feel safe?"

Rationale: Hallucinations are sensory perceptions that occur without external stimuli, often associated with schizophrenia. Clients who experience auditory hallucinations may hear voices that are threatening, derogatory, or commanding. The nurse should respond to the client's hallucinations with empathy, respect, and validation, while also assessing their risk for self-harm or harm to others. The nurse should also help the client cope with their hallucinations by providing distraction, reality orientation, medication administration, and environmental modification.

Incorrect options:

A) "Do you have a plan to harm yourself?" - This is an important question to ask when assessing suicide risk, but it does not address the client's hallucinations or provide any support or reassurance.

B) "The voices are not real and they cannot hurt you." - This is an invalidating response that contradicts the client's reality and may cause them to feel defensive or distrustful of the nurse.

C) "I don't hear any voices. What are they saying to you?" - This is a curious response that may reinforce the client's hallucinations or increase their anxiety.

Correct answer: D) All of the above.

Rationale: Autonomy is the ability to act independently and make choices based on one's own values and beliefs. Respect for autonomy is an ethical principle that guides the nurse-client relationship, especially in mental health settings. The nurse should demonstrate respect for the client's autonomy by informing the client about their diagnosis and treatment options, asking the client for their preferences and opinions regarding their care, and encouraging the client to participate in decision-making and goal-setting.

Incorrect options:

A) The nurse informs the client about their diagnosis and treatment options. - This is a correct action, but not the only one.

B) The nurse asks the client for their preferences and opinions regarding their care. - This is a correct action, but not the only one.

C) The nurse encourages the client to participate in decision-making and goal-setting. - This is a correct action, but not the only one.

Correct answer: A) "How do you feel today?"

Rationale: Mood is the subjective emotional state that the client experiences and reports. Mood can be assessed by asking the client how they feel today, or by using standardized scales such as the Hamilton Rating Scale for Depression or the Patient Health Questionnaire-9. Mood can be described using terms such as happy, sad, angry, anxious, or indifferent.

Incorrect options:

B) "How would you rate your energy level on a scale of 1 to 10?" - This is a question that assesses the client's physical functioning, not their mood.

C) "Do you have any thoughts of harming yourself or others?" - This is a question that assesses the client's suicidal or homicidal ideation, not their mood.

D) "How well are you able to concentrate and remember things?" - This is a question that assesses the client's cognitive functioning, not their mood.

Correct answer: D) All of the above.

Rationale: Fluoxetine (Prozac) is a selective serotonin reuptake inhibitor (SSRI) that is used to treat OCD and other anxiety disorders. SSRIs work by increasing the availability of serotonin in the brain, which helps regulate mood, anxiety, and compulsive behaviors. The nurse should include the following information in the teaching:

- The medication should be taken with food to prevent stomach upset, nausea, or vomiting.

- The medication should not be taken with alcohol, as this can increase the risk of adverse effects such as drowsiness, dizziness, or liver damage.

- The medication may cause sexual dysfunction as a side effect, such as decreased libido, erectile dysfunction, or delayed ejaculation. The client should report any changes in sexual function to their provider.

Incorrect options:

A) "You should take this medication with food to prevent stomach upset." - This is a correct information, but not the only one.

B) "You should avoid drinking alcohol while taking this medication." - This is a correct information, but not the only one.

C) "You may experience sexual dysfunction as a side effect of this medication." - This is a correct information, but not the only one.

Correct answer: B) Teach the client relaxation techniques such as deep breathing or progressive muscle relaxation.

Rationale: Flashbacks are vivid and intrusive recollections of a traumatic event that occur involuntarily and cause distress to the client. Flashbacks can be triggered by reminders of the trauma, such as sights, sounds, smells, or emotions. The nurse should help the client cope with flashbacks by teaching them relaxation techniques such as deep breathing or progressive muscle relaxation, which can help reduce anxiety and physiological arousal. The nurse should also stay with the client until they are calm and oriented.

Incorrect options:

A) Ask the client to describe the details of the traumatic event. - This is an inappropriate intervention that may worsen the client's distress and retraumatize them. It is important for the nurse to respect the client's boundaries and avoid pressuring them to discuss or relive the traumatic event unless the client initiates the conversation and feels comfortable doing so.

C) Remind the client that they are safe and that the flashbacks are not real. - While it is important to reassure the client that they are safe, simply reminding them that the flashbacks are not real may not be sufficient to alleviate their distress. Flashbacks can be very real and overwhelming for individuals with PTSD, and dismissing their experiences may invalidate their feelings. Instead, the nurse should focus on providing support, validation, and coping strategies such as relaxation techniques to help the client manage and reduce the intensity of their flashbacks.

D) All of the above. - This is an incorrect option, as asking the client to describe the details of the traumatic event and reminding them that the flashbacks are not real are not appropriate interventions for coping with flashbacks in clients with PTSD. Teaching relaxation techniques, however, is an effective and appropriate intervention for managing and coping with flashbacks.