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"Notify child protective services." Reporting to child protective services is only necessary if there is evidence of abuse, neglect, or an inability to provide adequate care. A diagnosis of borderline personality disorder alone does not warrant an automatic report.

"Suggest the children live with other relatives." Encouraging a client to relinquish custody without evidence of an inability to care for the children is not appropriate. Providing support and resources to enhance parenting skills is a more beneficial approach.

"Encourage the children to visit the psychiatric unit when the client is leaving." While family involvement is important, exposing young children to a psychiatric unit can be overwhelming and inappropriate. Alternative ways to support parent-child bonding should be considered.

"Interrupt the client's statement to clarify thoughts or ideas." Interrupting can disrupt the client’s thoughts and make them feel unheard. Active listening requires patience, allowing the client to speak fully before responding. Clarifications should be made after they finish to ensure understanding. Frequent interruptions may hinder trust and open communication.

"Show emotion when a client is disclosing sensitive information." While empathy is important, excessive emotional reactions can shift focus away from the client. A calm and composed demeanor helps maintain a supportive environment. Overreacting may make the client feel uncomfortable or hesitant to share. Active listening involves offering validation without overwhelming emotional responses.

"Keep direct eye contact to a minimum." Eye contact conveys attentiveness and respect, helping to establish rapport. Avoiding eye contact may make the client feel ignored or dismissed. However, excessive staring can be intimidating, so a balanced approach is best. Appropriate eye contact fosters trust and enhances communication.

"Ensure the client goes to group activities as planned." While group activities can promote socialization, a client experiencing confusion and thought distortions may struggle to participate. Forcing group engagement without addressing immediate needs can increase distress. Individualized interventions should be prioritized before encouraging group involvement. Ensuring safety and reducing anxiety are more immediate concerns.

"Give PRN medications to treat increased hallucinations." PRN medications may help manage symptoms but are not the first priority. Assessing and ensuring safety takes precedence before administering medications. The nurse should first provide reassurance and evaluate the severity of symptoms. Medication is important, but nonpharmacological interventions should be attempted first when possible. Ensuring safety remains the immediate concern in managing schizophrenia-related confusion.

"Use distraction such as the television or music." While distraction techniques can be beneficial, they do not directly address confusion or distorted thinking. The client may require more structured interventions to reorient them and provide reassurance. Music or television might help in stable periods but may not be effective in acute distress. Ensuring the client’s safety and reducing distress are higher priorities in immediate care.

"When attending dialectical behavior therapy." Dialectical behavior therapy (DBT) is specifically designed to help individuals with borderline personality disorder (BPD) manage emotions and reduce self-harming behaviors. While therapy can bring up distressing emotions, it provides structured support and coping strategies. The risk of self-harm is lower when clients are actively engaged in treatment and receiving professional guidance.

"When getting married." Major life changes, including marriage, can be stressful for individuals with BPD, but they do not inherently pose the highest risk for self-harm. Support from a partner and structured therapy can help navigate emotional challenges. While instability in relationships can trigger distress, the protective factors of marriage may reduce immediate risk. Self-harm risk is typically higher in periods of transition without support.

"When attending narrative therapy." Narrative therapy helps clients reframe their experiences and build a stronger sense of identity. Although deep emotional topics may be explored, structured therapy provides a safe space for expression. Therapeutic interventions aim to reduce distress and teach coping mechanisms, decreasing the likelihood of self-harm. The highest risk occurs when structured support is suddenly removed.

"Persistent depressive disorder is characterized by delusions and hallucinations." Psychotic features such as delusions and hallucinations are not typical of persistent depressive disorder (PDD). These symptoms are more commonly associated with major depressive disorder with psychotic features or schizophrenia. PDD primarily involves chronic low-grade depression rather than severe psychotic symptoms.

"Persistent depressive occurs shortly after taking or withdrawing from a substance." Substance-induced depressive disorder is a distinct diagnosis that results from drug use or withdrawal. Persistent depressive disorder is not caused by substance use but is a long-term mood disorder that lasts for at least two years. The symptoms are chronic and not directly linked to substance intake or withdrawal.

"Persistent depressive is characterized by both manic and depressive episodes." Bipolar disorder, not persistent depressive disorder, is characterized by alternating manic and depressive episodes. PDD involves a chronic, low-level depressive state without manic symptoms. Individuals with PDD may experience periods of worsening depression, but they do not exhibit the high-energy or euphoric states seen in bipolar disorder.

"Lip smacking and tongue thrusting." These symptoms are more characteristic of tardive dyskinesia, a side effect of long-term antipsychotic use, rather than lithium toxicity. Lithium toxicity primarily affects the gastrointestinal and neurological systems. While movement disorders can occur with severe toxicity, lip smacking and tongue thrusting are not typical early signs.

"Blurred vision and jerking motor movements." Severe lithium toxicity (levels above 2.0 mEq/L) can cause neurological impairments, including tremors, muscle rigidity, and seizures. However, at a level of 1.6 mEq/L, symptoms are generally milder and include gastrointestinal distress and coordination issues. Blurred vision and significant motor dysfunction are more indicative of advanced toxicity.

"Fever and fluctuating blood pressure." Autonomic instability, including fever and blood pressure fluctuations, is not a common manifestation of lithium toxicity. These symptoms are more characteristic of conditions such as serotonin syndrome or neuroleptic malignant syndrome. Lithium toxicity primarily presents with gastrointestinal, neurological, and coordination-related symptoms.

Diagnosis typically occurs after 40 years of age. Diagnosis typically occurs in late adolescence to early adulthood, not after 40 years of age. While late-onset schizophrenia can occur, it is less common. The disorder usually manifests in the late teens to early 30s, with males often presenting earlier than females.

Life expectancy is greater than the general population. Life expectancy is lower than the general population due to factors such as increased risk of suicide, cardiovascular disease, and reduced access to healthcare. The presence of comorbid conditions and lifestyle factors, including smoking and poor diet, further contribute to a shorter lifespan.

Co-occurring mental health illnesses are rarely diagnosed. Co-occurring mental health illnesses are frequently diagnosed in individuals with schizophrenia. Conditions such as depression, anxiety disorders, and substance use disorders are common. These comorbidities can complicate treatment and impact overall prognosis.

Inform the newly licensed nurse that they are successfully building trust and rapport. While therapeutic communication is essential, personalizing the interaction in this way crosses professional boundaries. Comparing a client to a family member can create unrealistic expectations and blur the nurse-client relationship. Maintaining professional distance ensures objective and ethical care.

Ask the newly licensed nurse if they are comfortable providing care to the client. While assessing a nurse’s comfort level is important, it does not address the boundary violation. The concern is not about the nurse's comfort but about maintaining professionalism in client interactions. Direct intervention is needed to correct the inappropriate statement and reinforce professional conduct.

Record that the newly licensed nurse is able to maintain professional nurse-client boundaries. The statement made by the newly licensed nurse demonstrates a boundary issue rather than professionalism. Nurses should establish rapport without over-identification with clients. Documenting that the nurse maintained boundaries would be inaccurate and fail to address the issue.

Inappropriate guilt is a common symptom of depression, but it does not involve false beliefs about being targeted. Clients with major depressive disorder may feel excessive guilt, but this differs from the fixed, false beliefs seen in delusions.

Mania is characterized by elevated mood, impulsivity, and hyperactivity rather than paranoid thoughts. While manic episodes may include grandiose delusions, the belief that a government agency is attempting to capture the client aligns more with persecutory delusions.

Confusion involves disorganized thinking, memory impairment, or difficulty understanding surroundings, often seen in delirium or cognitive disorders. While delusions can contribute to disorganized thoughts, they are distinct from general confusion.

"Do you think of yourself as more of an introvert? That makes a difference with how you socialize." Social withdrawal in schizophrenia is not related to personality traits like introversion. It is often an early symptom of the disorder, preceding more pronounced psychotic features. Focusing on introversion may mislead the client and overlook the underlying pathology.

"Were you avoiding your friend so that you could hear the voices more clearly?" This statement assumes the client was already experiencing auditory hallucinations, which is not always the case. Social isolation often predates the onset of hallucinations and delusions, making this explanation inaccurate. It may also come across as dismissive rather than informative.

"That is very interesting, We are not sure why people start to isolate themselves." While the exact cause of social withdrawal in schizophrenia is not fully understood, research indicates it is an early warning sign. Providing vague or uncertain information may leave the client feeling confused rather than supported in understanding their condition.