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The exhaustion stage occurs after prolonged exposure to stress when the body’s adaptive mechanisms are depleted. At this point, the individual may experience fatigue, decreased immunity, and increased vulnerability to illness. The symptoms described in the question—such as increased heart rate, elevated blood pressure, and heightened alertness—are acute and immediate responses, not signs of long-term depletion. Therefore, this stage does not fit the clinical presentation.

The resistance stage occurs if the stressor persists beyond the alarm phase. In this stage, the body attempts to adapt to the ongoing stress by maintaining elevated levels of cortisol and other stress hormones. While the body remains on high alert, the symptoms are less acute and more sustained, such as continued elevated blood pressure or suppressed immune function. The acute and immediate symptoms described in the question do not align with this stage.

The recovery stage refers to the period after the stressor has been removed, when the body returns to baseline functioning. Homeostasis is restored, and physiological parameters such as heart rate and blood pressure normalize. Since the client in the question is actively experiencing heightened physiological responses, this stage does not apply.

Discussing bias openly in front of the patient is inappropriate because it places the emotional burden on the patient and may damage trust. Patients may feel stigmatized or unsafe if the nurse verbalizes bias in the moment without first processing it privately. Professional practice requires self-reflection before engaging the patient in sensitive discussions.

Defending actions by citing protocols is a deflection strategy that prevents growth. Protocols do not eliminate bias; they only provide standardized procedures. A nurse who defends bias instead of acknowledging it risks perpetuating discriminatory behavior and undermining therapeutic relationships.

Avoiding interaction with the patient is harmful because it denies the patient necessary care and reinforces stigma. Withdrawal is not a solution to bias; instead, it worsens inequities and violates the nurse’s ethical duty to provide equitable care.

Assessing speech and behavior is only one component of a mental status examination. While important, it does not capture the full scope of cognitive functioning, mood, thought processes, and orientation. Limiting the exam to speech and behavior misses critical diagnostic information.

Determining the need for hospitalization may be an outcome of the assessment but is not its primary purpose. Hospitalization decisions depend on severity, risk of harm, and functional impairment, which are informed by but not limited to the mental status exam.

Identifying financial issues is not part of a mental status examination. While socioeconomic factors influence health, they are assessed through social history rather than cognitive and psychological evaluation.

Sharing personal experiences shifts focus away from the client and may blur professional boundaries. While intended to build rapport, it risks making the interaction about the nurse rather than the patient’s needs.

Asking direct and challenging questions can feel confrontational and may cause the client to withdraw. Therapeutic communication emphasizes safety and trust, not interrogation.

Using closed-ended questions limits the client’s ability to express themselves and restricts the depth of information gathered. It can make the conversation feel controlled rather than collaborative, undermining rapport.

Focusing exclusively on medical history is too narrow. While important, medical history alone does not capture psychosocial or emotional dimensions critical to mental health care.

Collecting biological data first emphasizes objectivity but neglects the holistic nature of mental health. Biological data must be integrated with psychosocial and emotional factors to provide a complete picture.

Financial and housing status are relevant but not primary in holistic assessment. They are part of social determinants but must be considered alongside emotional and physical health to avoid a fragmented approach.

Immediate referral to a culturally matched counselor may be helpful but is not always feasible or necessary. It bypasses the nurse’s responsibility to establish trust and may delay care.

Assertively encouraging expression can feel forceful and disrespectful to cultural norms. It risks alienating the patient and reinforcing reluctance.

Standardized questionnaires may provide data but do not address cultural nuances. Relying solely on tools risks misinterpretation and fails to build therapeutic rapport.

Increasing medication without prescriber consultation is unsafe and violates scope of practice. It risks adverse effects and undermines collaborative care.

Ignoring feelings invalidates the client’s experience and worsens anxiety. Therapeutic communication requires acknowledgment and support, not avoidance.

Focusing solely on deep breathing is too narrow. While beneficial, anxiety management requires a multimodal approach including lifestyle, coping strategies, and psychosocial support.

Avoidance of confrontation does not address the underlying defense mechanism. It may temporarily reduce stress but perpetuates maladaptive coping.

Mind-to-body strategies such as relaxation or mindfulness are helpful but do not specifically target scapegoating. They manage symptoms but not the root defense mechanism.

Pharmacologic intervention may reduce stress symptoms but is not the primary strategy for addressing scapegoating. Medication does not resolve maladaptive defense patterns and should be considered only if clinically indicated

Consistent treatment is not a consequence of stigma. In fact, stigma disrupts continuity of care because individuals may avoid seeking help or discontinue treatment prematurely due to fear of judgment.

Increased access is the opposite of what stigma causes. Stigma creates barriers, not opportunities, by discouraging engagement with mental health systems.

Improved outcomes are not associated with stigma. Instead, stigma worsens outcomes by delaying care, reducing adherence, and perpetuating inequities.