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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
a. Encourage the client to ignore these thoughts and feelings: This invalidates the client's experience and might hinder the therapeutic relationship.
b. Promote safety and immediately terminate the relationship with the client: Termination is a last resort, and transference can be a valuable tool for therapy if addressed constructively.
c. Immediately reassign the client to another staff member: This avoids the issue and doesn't address the underlying cause of transference.
d. Help the client to clarify the meaning of the relationship, based on the present situation. (Correct) Transference is a phenomenon where a client unconsciously redirects emotions and feelings from significant figures in their past onto the nurse. A therapeutic response involves acknowledging these feelings and helping the client explore them in a safe and supportive environment
Correct Answer is D
Explanation
a. Akathisia and hypersalivation. These side effects are uncomfortable but generally not immediately life-threatening.
b. Dry mouth and urinary retention. These side effects are concerning and should be monitored, but they do not typically require immediate intervention unless severe.
c. Akinesia and insomnia. While akinesia (lack of movement) and insomnia are significant, they are not immediately life-threatening symptoms.
d. Sore throat, fever, and malaise. This choice is correct because these symptoms could indicate agranulocytosis, a potentially life-threatening side effect of clozapine that requires immediate medical intervention.
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