At what point should the nurse determine that a client is at risk for developing mental illness? When:

a client communicates significant distress.

maladaptive responses to stress are coupled with interference in daily functioning.

thoughts, feelings, and behaviors are not reflective of the DSM-5 criteria.

a client uses defense mechanisms as ego protection.

Answer and Explanation

The Correct Answer is B

a. a client communicates significant distress. While significant distress is important to consider, it alone does not necessarily indicate a risk for developing mental illness unless it also impacts daily functioning and coping mechanisms.
b. maladaptive responses to stress are coupled with interference in daily functioning. This choice is correct because it reflects a combination of maladaptive coping (which can exacerbate mental health issues) and interference with daily functioning (a key indicator of mental illness according to DSM-5 criteria).
c. thoughts, feelings, and behaviors are not reflective of the DSM-5 criteria. While alignment with DSM-5 criteria is crucial for diagnosis, this choice alone does not address the risk aspect. The focus should be on behaviors that lead to impairment in daily functioning and coping.
d. a client uses defense mechanisms as ego protection. Using defense mechanisms is a normal part of human behavior and not necessarily indicative of mental illness risk unless these mechanisms are maladaptive and interfere with functioning.

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Correct Answer is A

Explanation

a. "There is a chemical imbalance of the brain, which leads to altered perceptions." Schizophrenia is a complex mental health disorder with a strong biological component. While the exact cause is unknown, it's believed to involve abnormalities in brain chemistry and neurotransmitters. This is a general explanation that avoids going into too much detail but acknowledges the biological basis of hallucinations.
b. "The hallucinations are caused by medication interactions." Hallucinations are a core symptom of schizophrenia and not necessarily caused by medication interactions.
c. "There is too little serotonin in the brain, causing delusions and hallucinations." While serotonin might be involved in schizophrenia, it's not the only neurotransmitter implicated.
d. Abnormal hormonal changes have precipitated auditory hallucinations." Hormonal changes might influence mood, but they are not the primary cause of auditory hallucinations in schizophrenia.

A. interrupt the handwashing and insist the client come to meals with everyone else. B. provide the client's meals later and after the other clients have eaten. C. notify the client when it is 30 minutes before the meal so they can begin their handwashing. D. allow the client to continue as is but provide them access to the kitchen.

Correct Answer is D

Explanation

a. Interrupt the handwashing and insist the client come to meals with everyone else. Interrupting ritualistic behaviors abruptly can increase distress and is not recommended. It may also reinforce the belief that the ritual is necessary.
b. Provide the client's meals later and after the other clients have eaten. This is not appropriate as it accommodates the OCD behavior and disrupts the mealtime routine for other clients.
c. Notify the client when it is 30 minutes before the meal so they can begin their handwashing. This is not appropriate as it enables the ritualistic behavior and may lead to increased anxiety if the client feels rushed to complete their ritual.
d. Allow the client to continue as is but provide them access to the kitchen. This is correct because it respects the client's autonomy while also providing an opportunity for gradual exposure therapy, where the client can work with the nurse to gradually reduce the time spent on rituals.

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At what point should the nurse determine that a client is at risk for developing mental illness? When:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 16-year-old client diagnosed with schizophrenia disorder experiences command hallucinations to harm others. The client's parents ask a nurse, "Where do the voices come from?" Which is the appropriate nursing response?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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