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A client who is a voluntary admission does not have the right to request to be discharged.This statement is incorrect. Clients admitted voluntarily to a mental health unit have the right to request discharge from the facility. However, there may be specific procedures and legal requirements to be followed for discharge, but the client ultimately has the right to request it.

A client who is admitted involuntarily cannot refuse to take prescribed psychotropic medications.
This statement is generally false. While involuntary admission may involve certain limitations on the client's autonomy, such as restrictions on leaving the facility, clients generally retain the right to refuse medications, including psychotropic medications. However, there are exceptions to this rule, such as when a client's refusal poses an imminent risk to their safety or the safety of others, in which case treatment may be provided following legal procedures.

A client who is a voluntary admission cannot withdraw consent after it has been given.This statement is incorrect. Clients who are admitted voluntarily have the right to withdraw their consent for treatment or participation in any aspect of their care, including interventions previously agreed upon. However, similar to involuntary admissions, there may be situations where treatment is deemed necessary for the client's well-being, and in such cases, withdrawal of consent may be overridden following appropriate legal processes.

RationalizationRationalization involves justifying or explaining behaviors, thoughts, or feelings in a rational or logical manner to make them acceptable to oneself or others. It is not typically associated with the inability to recall details of a traumatic event.

Undoing
Undoing is a defense mechanism characterized by engaging in acts or behaviors aimed at negating or "undoing" a previous undesirable thought, feeling, or action. It involves trying to make amends for perceived wrongdoings or mistakes, often through symbolic gestures. It is not typically associated with memory impairment related to trauma.

Reaction formationReaction formation is a defense mechanism where a person behaves in a manner that is opposite to their true feelings or impulses. For example, someone who feels hostility towards another person might display exaggerated friendliness. While reaction formation may be present in individuals with PTSD, it is not directly related to the inability to recall details of a traumatic event.

The client has acute bronchitisAcute bronchitis, an inflammation of the bronchial tubes typically caused by viral infections, is not directly associated with major depressive disorder. While physical health issues can impact mental health and exacerbate depressive symptoms, acute bronchitis is not a recognized risk factor for MDD.

The client has an elevated calcium level
Elevated calcium levels are not typically considered a risk factor for major depressive disorder. While imbalances in electrolytes like calcium can have physiological effects on the body, they are not directly linked to the development of depression.

The client is an only childBeing an only child is a demographic characteristic and is not considered a direct risk factor for major depressive disorder. While family dynamics and relationships can influence mental health, being an only child alone is not causally related to the development of depression.

Keep the client hospitalized until there is no longer a threatThis option involves the nurse making a decision regarding the client's hospitalization based on the perceived threat. However, nurses typically do not have the authority to unilaterally decide to keep a client hospitalized against their will solely based on a verbal threat. Such decisions would typically involve psychiatric evaluation and determination by mental health professionals.

Ensure the client's ex-partner is notified of the threatThis option involves notifying the potential victim about the threat made by the client. While it's important to ensure the safety of others, the nurse's legal duty primarily lies with protecting the confidentiality of the client's information. Without consent from the client or a legal obligation, such as mandatory reporting laws for imminent harm, the nurse cannot disclose the threat to the ex-partner.

Ask a friend or family member to monitor the client
Involving a friend or family member to monitor the client may not be a feasible or appropriate solution. It's crucial to address potential threats through appropriate channels and ensure the client receives proper evaluation and management by qualified professionals.

Flight of ideas: This speech pattern is characterized by rapidly shifting from one idea to another that are unrelated or loosely related. It often reflects disorganized thinking seen in conditions like mania or schizophrenia.

Neologisms: Neologisms are newly created words or phrases that have meaning only to the individual. They may be completely invented or may have personal significance to the speaker but are not understood by others.

Clang associations: Clang associations involve the stringing together of words based on similar sounds rather than logical connections. It often results in rhyming or repetitive speech patterns that lack coherence.

Document the client's behavior once every hour: Documenting the client's behavior at regular intervals is essential to monitor their condition while in restraints. However, hourly documentation might not be sufficient, especially if there are significant changes in the client's status or behavior.

Keep the client in restraints until the prescription expires: Restraints should be used for the shortest duration necessary to ensure the safety of the client and others. Keeping the client restrained until the prescription expires without reevaluation may not align with best practices for restraint use.

Conduct a debriefing regarding the client with the unit staff: Debriefing with the unit staff can provide an opportunity to discuss the client's behavior, response to interventions, and any concerns. This can help ensure continuity of care and identify any areas for improvement in managing similar situations in the future.

Use detailed explanations when providing education to the client: Providing detailed explanations can help the client better understand their condition and treatment, which is essential for managing obsessive-compulsive disorder (OCD). This intervention promotes client education and empowerment, enabling them to participate more effectively in their care and treatment.

Maintain a stimulating environment for the client: Individuals with OCD often benefit from a calm and organized environment rather than a stimulating one. A stimulating environment might exacerbate anxiety and OCD symptoms. Therefore, maintaining a calm and structured environment is typically more beneficial for clients with OCD.

Limit time for rituals to 20 minutes each day: Limiting time for rituals to a specific duration each day may not be appropriate or effective for all clients with OCD. While gradual exposure and response prevention (ERP) therapy may involve gradually reducing the time spent on rituals, setting a specific time limit may not address the underlying causes of OCD and could potentially increase anxiety and distress for the client.

Autonomic dysreflexia: This condition typically occurs in individuals with spinal cord injuries above the T6 level and presents with sudden, severe hypertension, bradycardia, headache, and profuse sweating. It is not typically associated with alcohol withdrawal symptoms such as visual hallucinations and impaired consciousness.

Synergistic effect: This term refers to the combined effect of two or more substances or factors being greater than the sum of their individual effects. While alcohol withdrawal can interact with other substances or conditions to produce various effects, it is not a specific condition causing visual hallucinations and impaired consciousness.

Sleep deprivation: Prolonged sleep deprivation can lead to cognitive impairment, mood disturbances, and hallucinations, but it is not typically associated with impaired consciousness as described in the scenario. Additionally, the manifestations described are more indicative of alcohol withdrawal rather than sleep deprivation alone.

Encourage the client to attend group therapy sessions: While group therapy can be beneficial for some individuals with panic disorder by providing support and opportunities for learning coping strategies, it may not be appropriate for all clients. Some clients may feel overwhelmed or anxious in group settings, especially during panic attacks. The nurse should assess the client's readiness and comfort level with group therapy and individualize the treatment plan accordingly.

Allow the client to choose scheduled daily activities: Providing the client with a sense of control and autonomy over their daily activities can be helpful in managing anxiety and panic symptoms. However, this intervention alone may not address the specific cognitive and behavioral aspects of panic disorder. It is important to incorporate other evidence-based interventions, such as cognitive-behavioral therapy (CBT) techniques, into the treatment plan to address the underlying causes of panic attacks.

Avoid discussing topics that can trigger a panic attack: While it is important to be mindful of potential triggers for panic attacks, avoiding all discussion of triggering topics may not be practical or helpful in the long term. Instead, the nurse should work collaboratively with the client to identify triggers and develop coping strategies to manage them effectively. Avoidance alone may reinforce avoidance behaviors and perpetuate anxiety.

These clients can receive packages after they are privately inspected by security: While security measures may be in place to ensure the safety and appropriateness of packages received by clients in a mental health facility, the ability to receive packages is not necessarily dependent on the client's involuntary admission status. Policies regarding package inspections may vary by facility and are not specific to involuntary admission status.

These clients can vote in local and federal elections: Involuntarily admitted clients retain certain civil rights, including the right to vote, unless restricted by a court order. However, the ability to exercise this right may vary depending on the individual's mental health status and legal status.

These clients cannot refuse their prescribed antipsychotic medications: Involuntarily admitted clients still have the right to refuse treatment, including medications, although there may be circumstances where treatment can be administered against their wishes, such as in cases of imminent harm to self or others. However, these decisions are typically made on a case-by-case basis and may involve legal and ethical considerations.

“Have you had a glass of wine in the last week?”: While this question assesses recent alcohol consumption, it does not specifically address problematic drinking patterns or consequences associated with alcohol use disorder.

“Do you drink alcohol with your friends?”: This question addresses social drinking behavior but does not specifically focus on the potential for alcohol use disorder or problematic drinking patterns.

"Do you enjoy drinking alcohol?”: While enjoyment of alcohol may be relevant to the overall assessment, it does not specifically address problematic drinking patterns or consequences associated with alcohol use disorder.

The right to parity: Parity refers to the equality or fairness in treatment or access to services. This right ensures that individuals are treated fairly and without discrimination. However, in situations where a client requires close observation due to safety hazards, ensuring parity may not be feasible or appropriate as the primary focus is on preventing harm and promoting safety rather than ensuring equal treatment.

The right to make informed decisions: This right emphasizes the client's autonomy and ability to make decisions about their care based on relevant information provided by healthcare professionals. While this right is fundamental in healthcare, in cases where a client poses a risk to their safety or the safety of others due to their condition, such as in cases requiring close observation, the client may temporarily forfeit the right to make informed decisions to ensure their safety.

The right to social contact: This right pertains to the client's ability to interact with others and maintain social connections, which are important for emotional well-being. However, in situations where a client requires close observation due to safety concerns, restrictions on social contact may be necessary to prevent harm or injury. For example, if a client exhibits behaviors that pose a risk to themselves or others, limiting social contact can help mitigate these risks and ensure the safety of all individuals involved.

Cognitive reframing:Cognitive reframing involves helping individuals change their perspective or interpretation of a situation to see it in a more positive or balanced light. While this technique can be helpful in various situations, it may not be suitable for addressing delusions or misconceptions in clients with dementia who firmly believe in their reality, such as the client who perceives a doll as her infant child.

Thought stopping:Thought stopping is a cognitive-behavioral technique used to interrupt or stop intrusive or distressing thoughts. It typically involves mentally or verbally interrupting negative thoughts with a cue word or phrase. However, this technique may not be effective for addressing the belief of a client with dementia that a doll is her infant child because it does not acknowledge or validate the client's reality.

Operant conditioning:Operant conditioning is a behavior modification technique based on the principles of reinforcement and punishment to strengthen or weaken behaviors. While it may be used to modify behaviors in some situations, it is not typically employed to address delusions or misconceptions in clients with dementia. Using operant conditioning techniques with a client who believes a doll is her infant child would not address the underlying emotional needs or provide therapeutic support for the client's reality.

The child has a history of jaw fractures: This finding suggests physical abuse rather than neglect. Jaw fractures are not typically associated with neglect unless they result from untreated medical conditions or lack of appropriate supervision.

The child seems frightened of their parent: This finding may indicate emotional abuse or exposure to domestic violence rather than neglect. While fearfulness can be a sign of maltreatment, it does not specifically indicate neglect unless it is related to the failure of the parent to provide adequate care.

The child rocks back and forth continually: This finding may suggest developmental delays or emotional distress but is not necessarily indicative of neglect on its own. However, if the rocking behavior is related to inadequate stimulation, supervision, or care from the caregiver, it could be considered a sign of neglect.

A client who has borderline personality disorder and exhibits splitting behaviorsWhile splitting behaviors can be concerning and may require intervention, they do not typically pose an immediate threat to the client's safety or well-being compared to other urgent issues such as hallucinations or medication side effects.

A client who recently started taking lithium and has a fine hand tremor
A fine hand tremor is a common side effect of lithium therapy and typically does not require immediate attention unless it becomes severe or interferes significantly with the client's functioning. Therefore, this client's assessment can be prioritized lower than the client experiencing command hallucinations.

A client who takes nicotine and states they have a dry mouthWhile a dry mouth can be uncomfortable, it is not typically a critical issue requiring immediate assessment compared to the safety concerns associated with command hallucinations in a client with schizophrenia.

Refer the client to a support group for survivors of suicide: While support groups can be valuable resources for individuals who have lost loved ones to suicide, it may not be the most immediate or appropriate action to take first. The client may not be ready to engage in group support until her immediate needs are addressed.

Offer to contact the client’s family or support system: This option demonstrates empathy and practical support by offering assistance in reaching out to the client's family or support system. It can help ensure that the client has immediate emotional support and assistance with practical matters.

Inform the client that feelings of guilt are often felt by survivors of suicide: While providing information about common experiences of survivors of suicide can be helpful, it may not be the most immediate action to take first. The client's emotional needs and immediate concerns should be addressed before discussing broader aspects of grief and guilt.

“I have had several negative pregnancy tests but know they are all wrong.”: This statement suggests a belief that contradicts objective evidence (negative pregnancy tests) and may indicate a somatic symptom disorder or a delusional disorder rather than illness anxiety disorder.

“I double-check my pills because I think the pharmacist may be putting poison in them.”: This statement reflects mistrust or paranoia about medications and the intentions of the pharmacist. While it involves health-related concerns, it may be more indicative of paranoid ideation or delusional beliefs.

“I feel really nervous when my partner goes to work, and I am home alone during the day.”: This statement describes anxiety related to separation from a partner and being alone, which is not a characteristic feature of illness anxiety disorder. It may be more indicative of generalized anxiety disorder or separation anxiety disorder.

"Have you thought about taking a sleeping pill?”: While this response acknowledges the client's report of feeling tired, it immediately jumps to suggesting a specific solution without exploring the underlying reasons for the fatigue. It also assumes that medication is the appropriate intervention without further assessment.

"Your fatigue will pass, and everything will be just fine.”: This response minimizes the client's concerns and feelings by dismissing them with a vague reassurance. It does not validate the client's experience or offer practical support.

"Do you have a family member who can assist you?”: This response acknowledges the client's difficulty with grocery shopping and offers a practical solution by asking about available support from family members. It encourages the client to explore their support system and potential resources.

“I can hear him crying in the middle of the night.”: While this statement indicates distress, it does not necessarily indicate an immediate risk of suicide. Crying can be a symptom of various emotional or psychological issues, but it does not provide direct evidence of suicidal intent.

"He spends most of his time locked in his room.”: Social withdrawal or isolating oneself from others can be a warning sign of depression or other mental health issues, including suicidal ideation. However, it alone may not indicate imminent risk of suicide.

“He refuses to go to the movies with his friends.”: Social withdrawal or a decline in interest in previously enjoyed activities can also be indicators of depression or other mental health concerns. However, like spending time alone, it does not provide direct evidence of suicidal intent.

“Decreased startle response to loud noises.”: Individuals with PTSD often have an exaggerated startle response to loud noises or unexpected stimuli. This heightened startle response is a common symptom of hyperarousal associated with PTSD. Therefore, a decreased startle response would be unexpected in this context.

“Reports uninterrupted sleep of 10 to 12 hr each night.”: Sleep disturbances are common among individuals with PTSD. Symptoms can include difficulty falling asleep, staying asleep, or experiencing nightmares related to the traumatic event. Therefore, reports of uninterrupted sleep for 10 to 12 hours each night would be unexpected in someone with PTSD.

“Reports feelings of acute distress that began 2 weeks ago.”: PTSD symptoms typically develop shortly after experiencing a traumatic event, but the diagnosis of PTSD requires that symptoms persist for at least one month. Acute distress that began two weeks ago may indicate an acute stress reaction rather than PTSD. PTSD involves persistent symptoms beyond the acute phase of the trauma.

A client who has new-onset delirium: Delirium is characterized by acute confusion and changes in cognition, often due to underlying medical conditions. Assertiveness training may not be appropriate for someone experiencing delirium, as their cognitive impairment may interfere with their ability to participate effectively in the therapy session.

A client who is experiencing auditory hallucinations: Auditory hallucinations involve perceiving sounds or voices that are not actually present. Assertiveness training may not directly address the underlying cause of auditory hallucinations, which typically require other therapeutic approaches such as medication management and cognitive-behavioral therapy.

A client who is experiencing mania: Mania is a state of elevated mood, increased energy, and often impulsivity. While assertiveness training could potentially be beneficial for individuals with bipolar disorder during periods of stability, it may not be appropriate during acute manic episodes when the client's judgment and insight may be impaired.

Reach to Recovery: Reach to Recovery is a program offered by the American Cancer Society that provides support and resources to individuals facing breast cancer. While support is crucial for individuals facing cancer, it is not directly related to alcohol withdrawal.

Al-Anon: Al-Anon is a support group specifically designed for family members and friends of individuals struggling with alcohol addiction. While it may not be directly applicable to the client themselves, it could be beneficial for their family members or loved ones.

Light therapy: Light therapy, also known as phototherapy, is a treatment used for conditions such as seasonal affective disorder (SAD) or certain types of depression. While it can be helpful for individuals experiencing mood disturbances, it is not typically recommended specifically for alcohol withdrawal.

“This medication can cause my child to have low blood sugar.”: This statement is not accurate. While risperidone can cause side effects such as weight gain and metabolic changes, low blood sugar is not a common side effect associated with this medication.

“This medication won't require my child to have routine lab tests.": This statement is incorrect. Routine monitoring, including blood tests, may be necessary while taking risperidone to monitor for potential side effects such as changes in blood sugar, cholesterol levels, and liver function.

“This medication might need to be increased if my child has muscle spasms.": This statement is partially accurate. Muscle spasms or extrapyramidal symptoms can be side effects of risperidone. However, the medication would typically be adjusted or possibly decreased if these side effects occur, rather than increased.

Provide additional attention to the client: While individuals with BPD may crave attention and validation, providing excessive attention can reinforce maladaptive behaviors. Instead, the focus should be on providing consistent and appropriate support while also setting boundaries to encourage healthy coping mechanisms.

Apply mechanical restraints before administering medication: Mechanical restraints should only be used as a last resort when less restrictive interventions have failed to ensure the safety of the client and others. Applying restraints before attempting other interventions is not appropriate and may escalate the situation.

Limit staff members who work with the client: Limiting staff members who work with the client may inadvertently isolate the client and hinder the development of therapeutic relationships. Consistency in staffing and a collaborative approach among team members are often more beneficial in providing comprehensive care.