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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.

Nurses do not have the authority to unilaterally detain clients in a hospital. This decision is typically made by a physician or a legal authority, especially in the context of a medical-surgical unit where mental health professionals may need to be involved. Keeping a client hospitalized without proper legal procedures and mental health evaluation could lead to legal repercussions for unlawful detainment.

While involving family or friends might provide support, it is not a sufficient or appropriate response to a threat of harm. It does not address the immediate risk posed to the ex-partner and may not comply with legal obligations.

Transferring the client to a mental health facility for further evaluation and treatment might be necessary, but it must be done through appropriate medical and legal channels. It addresses the need for a thorough mental health assessment and ensures that the client receives the necessary care.

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.

Documentation should occur every 15-30 minutes to ensure the client's safety and to assess the need for continuing or removing the restraints.

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.

Typically, the evaluation should occur within 1-4 hours depending on the facility's policy and the urgency of the situation.

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.