Choice A rationale: Asking the client what they think should happen is vague and does not offer any direction or support.

Choice B rationale: This response encourages is vague and does not offer any direction or support but instead puts the burden of decision-making on the client who is overwhelmed and distressed.

Choice C rationale: Inquiring about the seriousness of the collision is important but may not be the most immediate concern when the client is seeking guidance on what to do.

Choice D rationale: This response shows empathy and concern for the client's well-being and helps the client take action to cope with the crisis.

Choice A rationale: While frustration may contribute to distress, the client's recent life events, such as a breakup and job loss, suggest a stronger link to a sense of loss.

Choice B rationale: Experiencing a divorce, job loss, and recent breakup are significant life events that contribute to a profound sense of loss, which can lead to feelings of depression.

Choice C rationale: Poor self-esteem can contribute to depression, but the client's recent life events are more directly related to the current feelings of depression.

Choice D rationale: While a lack of intimate relationships can impact mental health, the recent breakup is a more immediate factor contributing to the client's depression.

Choice A rationale: Altruism involves addressing one's own needs through meeting the needs of others, and caring for the husband's aging parents is an example of this coping mechanism.

Choice B rationale: Regression involves reverting to an earlier stage of development, which is not evident in the scenario.

Choice C rationale: Compartmentalization is the defense mechanism of separating conflicting thoughts or feelings, which is not clearly identified in the scenario. Choice D rationale: Egocentrism involves seeing the world from only one's own perspective, which is not the primary issue in the scenario.

Choice A rationale: Waiting for the client to respond allows for a patient-centered approach, respecting the client's pace and giving them the opportunity to express themselves when ready.

Choice B rationale: Assuming the client's ability to hear the question may be accurate, but the client's nonverbal cues suggest a need for patience and a non-coercive approach.

Choice C rationale: Changing the question may not address the client's current feelings and might disrupt the therapeutic process.

Choice D rationale: Returning at a later time might be appropriate if the client continues to be unresponsive, but it is not the initial action in this situation.

Choice A rationale: Monitoring for binging activities is important, but addressing the potential physiological complications of bulimia, such as electrolyte imbalances, takes precedence.

Choice B rationale: Assessing and reporting the client's electrolyte status is the highest priority as bulimia nervosa can lead to severe electrolyte imbalances, which may result in life-threatening complications.

Choice C rationale: Assigning care based on age is not a priority in addressing the immediate health risks associated with bulimia nervosa.

Choice D rationale: While group therapy is beneficial, addressing the client's physical health and safety is the highest priority.

Choice A rationale: Thiamine (vitamin B1) is the appropriate medication for Wernicke Korsakoff syndrome, as it addresses thiamine deficiency associated with chronic alcohol use, which can contribute to neurological symptoms.

Choice B rationale: Chlordiazepoxide is a benzodiazepine used for alcohol withdrawal symptoms but does not address the underlying thiamine deficiency in Wernicke Korsakoff syndrome.

Choice C rationale: Clonidine is not indicated for the treatment of Wernicke-Korsakoff syndrome; it is primarily used for managing withdrawal symptoms in opioid or alcohol dependence.

Choice D rationale: Carbamazepine is not the appropriate medication for Wernicke Korsakoff syndrome; it is commonly used for mood stabilization in conditions like bipolar disorder.

Choice A rationale: While assessing for symptoms of cocaine withdrawal is important, educating the client about the purpose and side effects of the medication is the priority when initiating new pharmacological treatment.

Choice B rationale: Educating the client about the purpose and side effects of the medication promotes understanding and adherence to the treatment plan, addressing the client's cravings.

Choice C rationale: Encouraging the client to take the medication as prescribed is important, but educating them about the medication takes precedence.

Choice D rationale: Determining when the client last used cocaine is relevant but does not directly address the education needed for medication management.

Choice A rationale: Giving concise and firm directions for hygiene and dressing helps provide structure and support during periods of manic behavior.

Choice B rationale: Engaging the client in competitive activities may exacerbate manic symptoms, so it is not the best approach.

Choice C rationale: Assigning the client to a single room provides a quieter and less stimulating environment, promoting a more controlled and therapeutic setting. Choice D rationale: Inviting the client for a walk when their energy is high allows for a structured outlet for excess energy and may help with symptom management.

Choice E rationale: Providing television programs with suspense may contribute to overstimulation and is not the best approach during manic episodes.

Choice A rationale: Administering an antianxiolytic medication may be appropriate, but addressing the client's fluid and electrolyte imbalance is the priority.

Choice B rationale: Inserting a fecal management tube is not the first action to take in response to hemoccult positive liquid stools; addressing fluid balance is more urgent.

Choice C rationale: Inserting a peripheral intravenous catheter is the priority to address the client's fluid and electrolyte imbalance and provide necessary hydration and medications.

Choice D rationale: Crushing pills and placing them in applesauce may be considered, but the client's fluid and electrolyte imbalance needs prompt attention first.

Choice A rationale: Remaining calm and using a matter-of-fact approach helps provide a sense of security and reduces anxiety in the client during admission.
Choice B rationale: Assisting the client in developing alternative coping skills is important but may not be the first action during the initial admission process.

Choice C rationale: Administering a sedative may be considered if the client's anxiety is severe, but understanding and addressing the underlying cause of anxiety is the priority.
Choice D rationale: Asking the client why she is anxious may be appropriate, but the initial focus is on providing a calming and supportive environment during admission.

Choice A rationale: Headaches can be associated with various factors and are not specific to depression.

Choice B rationale: Back pain can have multiple causes and is not specific to depression. Choice C rationale: Dizziness may have various causes and is not specific to depression. Choice D rationale: Excessive tiredness (fatigue) is a common symptom of depression and often associated with the overall low energy levels experienced by individuals with depressive disorders.

Choice A rationale: Fear of large dogs may or may not be related to schizophrenia; other information is needed to determine its significance.

Choice B rationale: Decreased attention to detail is a symptom that may be observed in schizophrenia, but it is not the primary behavior to notify the healthcare provider.

Choice C rationale: Social withdrawal is a concerning behavior in schizophrenia that may indicate worsening symptoms and should be reported to the healthcare provider.

Choice D rationale: Changes in appetite are important to monitor but may not be the primary indicator of a worsening condition in schizophrenia.

Choice A rationale: Providing teaching on the symptoms of substance use dependence may be appropriate, but supporting the client's desire for positive changes is the immediate priority.

Choice B rationale: Advising the client to reschedule is not supportive of their current motivation for change.

Choice C rationale: Supporting the client to list small behavioral changes needed aligns with the client's expressed desire for a healthier lifestyle and is consistent with motivational interviewing techniques.

Choice D rationale: Explaining specific relapse prevention skills may be useful later in the recovery process, but initially supporting the client's motivation for change is the priority.

Choice A rationale: The client should avoid all alcohol, not limit consumption to one drink per day.

Choice B rationale: Avoiding all alcohol-containing products while on disulfiram is crucial to prevent a severe reaction called the disulfiram-alcohol reaction.

Choice C rationale: Operating heavy machinery is not a specific concern with disulfiram; avoiding alcohol is the primary focus.

Choice D rationale: Disulfiram can be taken with or without food, and taking it on an empty stomach is not necessary.

Choice A rationale: Asking about a bad experience may provide additional information, but it does not directly address the behavioral aspect of obsessive-compulsive disorder (OCD).

Choice B rationale: This response shows empathy and curiosity and invites the client to explore their cognitive processes behind their compulsive behavior. The nurse can help the client identify and challenge their irrational or distorted thoughts that fuel their anxiety and drive them to check the locks repeatedly.

Choice C rationale: Acknowledging that repeating the same behavior helps diminish anxiety might reinforce the client's belief that checking the locks is necessary and beneficial, which could prevent them from seeking alternative coping strategies.

Choice D rationale: Stating that feelings of being driven are related to anxiety is a general observation and may not contribute to a deeper understanding of the client's experience with OCD.

Choice A rationale: Abrupt discontinuation of alprazolam, a benzodiazepine used to treat anxiety disorders, can lead to withdrawal symptoms, including rebound anxiety,

insomnia, and potentially seizures. The statement reflects an understanding of the importance of gradual tapering and not abruptly stopping the medication. Choice B rationale: Reporting side effects such as dizziness, lightheadedness, or sedation is important, but the key focus for long-term benzodiazepine use is the need to avoid abrupt discontinuation.

Choice C rationale: While attending therapy sessions is beneficial for managing anxiety, the question is specifically addressing the self-care goal related to medication use. Choice D rationale: Reporting any decrease in anxiety using a 10-point scale is relevant but not as crucial as emphasizing the avoidance of abrupt discontinuation.

Choice A rationale: Speaking calmly and assuring the client of safety is a therapeutic intervention for managing severe anxiety and panic. It helps provide a sense of reassurance and safety to the client during an acute anxious episode.

Choice B rationale: Attempting to distract the client can be helpful in some situations, but in severe anxiety, the focus should initially be on providing a sense of safety and addressing immediate distress.

Choice C rationale: Helping the client identify thoughts is more appropriate during less acute moments or in the context of cognitive-behavioral therapy. In severe anxiety, the immediate focus is on providing support and reassurance.

Choice D rationale: Exploring past behaviors may be part of a comprehensive assessment but is not the first priority during an acute episode of severe anxiety.

Choice A rationale: Screening the client for domestic violence requires a more comprehensive assessment and interpretation of findings, which is beyond the scope of practice for the UAP.

Choice B rationale: Determining the client's risk for suicide involves complex judgment and should be assessed by a licensed healthcare provider, not a UAP.

Choice C rationale: Asking the client to state a chief complaint for admission involves initial communication and assessment skills, which should be performed by licensed nursing staff.

Choice D rationale: Obtaining a baseline set of vital signs is a routine task that can be delegated to the UAP. It is a non-complex and standard part of the admission process.

Choice A rationale: Remaining silent does not necessarily indicate disapproval; it is a therapeutic communication technique to allow the client to express feelings without interruption.

Choice B rationale: While the client may be experiencing sadness, the nurse's silence is not reflecting the client's emotions but rather providing space for the client to express their thoughts and feelings.

Choice C rationale: Silence, in this context, is therapeutic because it allows the client time and space to reflect on and explore their own thoughts and feelings. It promotes self-discovery and expression.

Choice D rationale: Respecting the client's loss is a general principle, but the specific therapeutic use of silence in this situation is to allow the client to process and express their emotions.

Choice A rationale: While accurate, emphasizing the potential lethality of cocaine may not be the most effective response to the student's statement.

Choice B rationale: While true, this response may be perceived as confrontational and may not be the initial approach to someone expressing confidence in their ability to control drug use.

Choice C rationale: Denial is a common response to potential substance abuse problems. Addressing this defense mechanism by acknowledging its existence may open the door to further discussion and exploration.

Choice D rationale: While true, directly stating that mind-altering drugs take away one's ability to make good decisions might be perceived as confrontational and may not facilitate a constructive conversation.

Choice A rationale: Disrupted sleep is a common symptom of postpartum depression, and clients may experience difficulty falling asleep or staying asleep.

Choice B rationale: Grandiosity is more indicative of bipolar disorder (mania) rather than postpartum depression.

Choice C rationale: Poor concentration is a common cognitive symptom associated with postpartum depression.

Choice D rationale: Compulsive behavior is not typically associated with postpartum depression.

Choice E rationale: Sadness is a hallmark symptom of depression, including postpartum depression.

Choice A rationale: The nurse's response regarding watery eyes and diarrhea is not directly related to the client's concern about the medication's effect on blood glucose levels.

Choice B rationale: This response minimizes the potential side effects, which is not accurate. Second-generation antipsychotics are associated with metabolic side effects, including changes in blood glucose levels.

Choice C rationale: Offering an education sheet is helpful but does not directly address the client's specific concerns about the medication's impact on blood glucose levels.

Choice D rationale: This response acknowledges the client's concern, provides information about the general tolerability of the medication, and invites the client to share more about their specific worries. It encourages open communication and allows the nurse to address the client's concerns more effectively.

Choice A rationale: A body mass index (BMI) of 21 is within the normal range and does not require immediate notification to the healthcare provider.

Choice B rationale: A blood pressure of 110/70 mm Hg is within the normal range for an adolescent and does not require immediate notification.

Choice C rationale: A potassium level of 2.9 mEq/dL (2.9 mmol/L) is below the normal range (hypokalemia) and requires notification to the healthcare provider due to the potential for adverse effects on cardiac and neuromuscular function.

Choice D rationale: A WBC of 10,000/mm3 (10 x 109/L) falls within the normal range and does not require immediate notification.

Choice A rationale: Hydrochlorothiazide is a diuretic and may contribute to electrolyte imbalances, but it is not the most concerning medication in this situation. Choice B rationale: Phenelzine is a monoamine oxidase inhibitor (MAOI), and the combination of an MAOI with certain foods or medications containing tyramine can lead

to a hypertensive crisis. The client's elevated blood pressure is of concern, and the nurse should notify the healthcare provider.

Choice C rationale: Losartan is an angiotensin II receptor blocker (ARB) used to treat hypertension. While it may contribute to blood pressure control, it is not the most concerning medication in this scenario.

Choice D rationale: Aspirin, at a dose of 81 milligrams, is often used for cardiovascular prophylaxis and is not the most concerning medication in this situation.

Choice A rationale: Alkaline phosphatase is not typically associated with the monitoring of lithium therapy. The primary concern is renal function.

Choice B rationale: Blood glucose is not the most critical parameter to monitor before initiating lithium therapy. The focus is on renal function.

Choice C rationale: White blood count is not the primary laboratory value to assess before starting lithium. Renal function is more critical.

Choice D rationale: Serum creatinine is the most important laboratory finding to review before beginning lithium therapy. Lithium is primarily excreted by the kidneys, and impaired renal function can lead to lithium toxicity. Regular monitoring of renal function, including serum creatinine levels, is crucial to prevent adverse effects.