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An adolescent client who throws objects at other clients:Seclusion is contraindicated for this client due to safety concerns. The behavior of throwing objects at others indicates a potential danger to both the client and others in a confined space. Placing the client in seclusion could escalate the situation and potentially lead to further harm.

Seclusion might be contraindicated for this client as well. Older adults experiencing manic behavior and emotional distress could be further traumatized by seclusion. Alternatives like providing a calm and soothing environment, along with appropriate medications, might be more beneficial for this client.

Seclusion is a potential option for this client. The repeated attempts to bite staff pose a risk of physical harm to both the client and staff members. Seclusion might be used as a last resort to ensure the safety of everyone involved.

Bleeding is not a common adverse effect of haloperidol, which is an antipsychotic medication used to treat conditions like schizophrenia. Haloperidol primarily works on the central nervous system and is not known to directly cause bleeding issues.

Cataracts are not a common adverse effect of haloperidol either. While long-term use of some antipsychotic medications can lead to metabolic and endocrine disturbances, which might indirectly impact eye health, cataracts are not a direct and immediate concern with haloperidol use.

Pancreatitis is not a common adverse effect of haloperidol. Pancreatitis typically involves inflammation of the pancreas and can be caused by various factors such as gallstones, alcohol consumption, and certain medications. Haloperidol is not known to directly cause inflammation of the pancreas.

Physical activity or exercise, such as running, does not inherently put the client at risk for lithium toxicity. However, excessive sweating due to vigorous exercise can lead to dehydration, which could affect lithium levels. Dehydration may lead to reduced kidney function, which could slow the excretion of lithium, potentially increasing the risk of toxicity.

The client drinks 2 liters of liquids daily:Explanation: Adequate fluid intake is generally important, but it is not a direct risk factor for lithium toxicity. In fact, staying hydrated can be beneficial for overall health and proper kidney function, which plays a role in lithium excretion.

Foods high in tyramine are a concern when taking certain classes of antidepressants called monoamine oxidase inhibitors (MAOIs). Lithium does not interact with tyramine-containing foods in the same way. Tyramine-rich foods are associated with a "cheese effect" when combined with MAOIs, but this is not relevant to lithium toxicity.

Placing locks at the top of doors leading outside is a safety measure to prevent the person with Alzheimer's disease from wandering or getting lost. While this does show that the partner is taking proactive steps to ensure the client's safety, it is not necessarily indicative of caregiver role strain.

Hiring a house cleaner can be a sign of caregiver role strain. Caregivers often become overwhelmed with the responsibilities of caring for a person with Alzheimer's disease, and hiring help for household tasks can be an indication that they are finding it challenging to manage everything on their own.

While redirecting the client when they're frustrated shows that the partner is using appropriate strategies to manage challenging behaviors associated with Alzheimer's disease, this observation doesn't necessarily indicate caregiver role strain.

While it's important to understand the client's perspective, this response might come across as confrontational or judgmental. It's better to create an open and non-judgmental environment for the client to share their feelings.

This response assumes that the client has parents to talk to and may not be relevant for all clients. It's also important to establish trust and rapport with the client before asking about their support network.

This response validates the client's feelings and provides empathy. While it's empathetic, it might not prompt further discussion to gather more information about the situation, which is important for a comprehensive assessment.

This response might come across as dismissive or insensitive to the partner's feelings. It's important to acknowledge the partner's emotions and offer support rather than suggesting they should calm down.

While it's reassuring to say that the patient will be fine, dismissing the partner's feelings and concerns is not supportive. The partner needs a chance to express their emotions and concerns.

This response might come across as accusatory or confrontational, which could exacerbate the partner's feelings of guilt. Instead, the nurse should focus on providing support and understanding.

This statement is incorrect. Chlorpromazine is not used as a medication to aid in smoking cessation. It is primarily used to treat conditions such as schizophrenia and other psychotic disorders.

This statement is incorrect. Flu-like symptoms are not a common side effect of chlorpromazine. Side effects more commonly associated with chlorpromazine include drowsiness, dizziness, and movement-related issues.

This statement is incorrect. While chlorpromazine can cause various side effects, increased frequency of urination is not one of the typical side effects associated with this medication.

Administering a sleeping medication should not be the first response, especially if the client is agitated. It's important to address the underlying cause of the agitation and consider other interventions before resorting to medication.

Encouraging the client to go back to bed might not be effective if they are experiencing significant distress or anxiety. It's better to address their emotional state first before suggesting any changes in activity.

This is a reasonable course of action. Exploring alternatives to the client's current behavior can help address their distress and find ways to manage their emotions more effectively.

Administering a sleeping medication should not be the first response, especially if the client is agitated. It's important to address the underlying cause of the agitation and consider other interventions before resorting to medication.

Encouraging the client to go back to bed might not be effective if they are experiencing significant distress or anxiety. It's better to address their emotional state first before suggesting any changes in activity.

This is a reasonable course of action. Exploring alternatives to the client's current behavior can help address their distress and find ways to manage their emotions more effectively.

This response reflects active listening and acknowledges the client's emotions. It's a reflective statement that shows empathy without making judgments.

While this response attempts to be positive and uplifting, it might not fully validate the client's feelings of worthlessness. It's important to acknowledge the client's emotions before trying to provide a more positive perspective.

This response normalizes the client's feelings, letting them know that their experience is understood and not uncommon. However, it might come across as somewhat dismissive if not followed by further validation and support.

This action might be premature. MAOIs (Monoamine Oxidase Inhibitors) are a class of antidepressants with specific dietary and medication interactions. They are typically considered when other classes of antidepressants have not been effective. It's important to exhaust other options before considering a switch to MAOIs.

It might be too early to consider changing the medication after just two weeks, especially since the client reports an improved appetite. Changes in dosage or medication should ideally be discussed with the provider after an adequate trial period.

While sleep problems can be associated with depression, it might not be the most appropriate next step based solely on the information provided. It's more important to address the ongoing depressive symptoms before focusing solely on sleep.

While respecting a client's right to privacy is important, when there's a threat of harm to an individual, it becomes a matter of safety that takes precedence over confidentiality.

This statement is incorrect. When there's a credible threat to harm an individual, waiting for a court order is not an appropriate or timely response. Immediate actions should be taken to ensure safety.

While involving the psychiatrist is important for the client's overall care, it's essential to take more immediate steps to ensure the safety of the potential victim, such as notifying the appropriate authorities or taking appropriate precautions.

This response might come across as confrontational or defensive, which could discourage the client from opening up further. It's important to offer support and understanding rather than putting the client on the spot.

While it's true that the client's family visits, depression often distorts perception and emotions. Telling the client that people care might not be fully effective in addressing their feelings of worthlessness.

This response opens the door for the client to express their emotions and thoughts. It encourages further conversation and helps the nurse understand the underlying causes of the client's feelings.

Disorganized speech is a symptom often associated with various mental health conditions, including schizophrenia, but it is not specific to acute mania. It might indicate cognitive impairment or thought disorder, but it's not a hallmark of acute mania.

Weight gain is not a typical hallmark of acute mania. In fact, during manic episodes, individuals might experience decreased appetite and sleep, leading to potential weight loss.

Dressing in all black is not a specific sign of acute mania. While changes in clothing choices or appearance can sometimes be associated with mood changes, this finding alone is not indicative of acute mania.

Regression is a defense mechanism in which a person reverts to an earlier stage of development in response to stress or anxiety. For example, an adult might start behaving like a child when faced with a difficult situation. In this case, the student berating the teacher doesn't demonstrate a return to an earlier developmental stage, so regression is not the correct choice.

Conversion refers to the conversion of emotional distress into physical symptoms, such as experiencing physical pain without any apparent physical cause. This mechanism is often seen in conditions like conversion disorder. The student berating the teacher is not exhibiting physical symptoms as a response to emotional distress, so conversion is not the correct choice.

Undoing involves trying to compensate for or negate an unacceptable action or thought with a contrary action. For instance, someone who had angry thoughts might engage in excessive acts of kindness to "undo" those thoughts. The student berating the teacher is not engaging in actions to negate their negative feelings or thoughts; they are expressing their frustration directly.

While this response attempts to engage the client in a conversation, it doesn't directly address the immediate concern of suicidal thoughts. It's important to prioritize assessing the client's safety before exploring their feelings about their family's perspective.

While understanding the client's history and the onset of their feelings is important, it's not the priority response in this situation. Assessing the client's risk of harm takes precedence over gathering historical information.

This response doesn't directly address the client's statement about being better off gone and doesn't assess the immediate risk of self-harm or suicide. While understanding the client's current situation is valuable, safety concerns should be addressed first.

Tactile hallucinations involve false sensations of touch, such as feeling something on the skin that isn't there. While these hallucinations can be distressing, they are not typically considered a priority over other types of hallucinations, especially those that might pose more immediate risks.

Visual hallucinations involve seeing things that aren't actually present. While these can be distressing, they are generally considered less urgent compared to command hallucinations, which can directly lead to risky actions.

Gustatory hallucinations involve false perceptions of taste. While these can be unsettling, they are not typically considered a priority over command hallucinations, which have a more immediate potential for harm.

While self-defense techniques can be useful information, discussing them immediately after a traumatic event like sexual assault may not be appropriate. The client's immediate needs for emotional support, medical evaluation, and safety are more pressing.

In cases of sexual assault, preserving evidence is important for legal purposes and for the client's well-being. Providing a bed bath could potentially compromise evidence and hinder a thorough examination by healthcare professionals.

Preserving evidence is crucial in cases of sexual assault, especially if the client intends to involve law enforcement. Informing the client about the importance of photographs for a police report is appropriate and can contribute to a potential legal investigation.

Providing an activity schedule that changes from day to day might be overwhelming and confusing for a client with Alzheimer's disease, as routine and predictability are often more beneficial.

Constantly rotating caregivers can lead to increased confusion for the client, as familiarity and consistency are important in their care.

Limiting time for the client to perform activities can add unnecessary stress and may not be conducive to a comfortable and supportive environment for someone with Alzheimer's disease.

This statement is incorrect. Risperidone is not typically associated with significant increases in blood pressure. One of the potential side effects of risperidone is orthostatic hypotension, which is a drop in blood pressure when changing positions (e.g., standing up quickly). Therefore, this choice is not the best instruction to include in the teaching.

This statement is incorrect. While risperidone can have side effects, flu-like symptoms are not commonly associated with it. Common side effects of risperidone may include dizziness, drowsiness, weight gain, and movement disorders. Flu-like symptoms are not a typical adverse effect of this medication.

This statement is incorrect. Muscle twitches are not a common side effect of risperidone. While it's true that some movement disorders can occur with antipsychotic medications, the statement is too specific to muscle twitches and does not accurately reflect the typical side effect profile of risperidone.