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Hypervigilance is a heightened state of sensory sensitivity and alertness, often seen in PTSD. It involves scanning the environment for threats and being easily startled. This is not the same as derealization, which is about altered perception of reality rather than increased alertness. Confusing the two would misinform the patient.

The description in this choice actually refers to depersonalization, not derealization. Depersonalization is the sense of being detached from oneself, as if observing one’s own actions from outside the body. While depersonalization and derealization often co-occur, they are distinct phenomena. This choice is therefore inaccurate for derealization.

Derealization is not a therapy; it is a symptom. Therapy for PTSD may include cognitive behavioral therapy, EMDR, or exposure therapy, but derealization itself is not a treatment modality. This choice is incorrect because it mislabels a symptom as an intervention.

Frequent relocations and separations are challenges of military life, but they are not paradoxical. They are predictable consequences of service obligations and deployments. While stressful, they do not represent a contradiction in values or structure.

The opportunity to travel and see different parts of the world is a benefit of military service. It is not paradoxical because it aligns with the expectations of global deployment. This is a straightforward advantage rather than a contradictory element.

Job security and guaranteed paychecks are positive aspects of military service. They provide stability and predictability, which are not paradoxical. This choice reflects a benefit rather than a contradiction.

Severe intellectual disability usually involves deficits across multiple domains, including psychomotor skills. Coordination problems are common, but psychomotor skills are often delayed or impaired beyond that. Suggesting they are unaffected minimizes the extent of disability and is inaccurate.

Clients with severe intellectual disability generally require assistance with most self-care activities. While those with moderate intellectual disability may perform some tasks independently, severe cases usually need continuous support. This choice overestimates their functional independence.

Advanced speech development is not typical in severe intellectual disability. Language skills are profoundly limited, often restricted to single words or simple phrases. Advanced speech would be inconsistent with the severity of impairment.

Referring the client back to the acupuncturist avoids answering the question and does not provide therapeutic communication. Nurses should give accurate, evidence-based information when asked about treatments.

While serotonin and norepinephrine are involved in pain modulation, acupuncture is not specifically known to increase their production. This explanation is misleading and not supported by evidence.

Suggesting HIV risk is inappropriate and inaccurate. Acupuncture performed with sterile, disposable needles carries minimal risk of infection. This response is fear-inducing and unprofessional.

Dementia is not caused by lack of activity group participation. This statement is inaccurate and misleading.

Activity groups are not limited to high-functioning clients. They are designed to provide stimulation and orientation for all residents, regardless of cognitive level.

Excusing the client from groups without explaining their benefits disregards the therapeutic value of structured activities. It also undermines the nurse’s role in promoting holistic care.

Frequently modifying the daily schedule can increase confusion and anxiety in clients with cognitive impairment. Consistency is more beneficial than variety in this population.

Leaving the client alone in the bathroom may compromise safety and increase risk of falls or injury. It does not promote self-esteem and may cause distress.

Assigning a variety of caregivers can reduce consistency and increase confusion. Clients with marked confusion benefit from familiar caregivers to build trust and security.

Anxiety disorders involve excessive worry, fear, or panic but do not typically include delusions or hallucinations. This presentation is not consistent with anxiety.

ADHD involves inattention, hyperactivity, and impulsivity. It does not cause psychotic symptoms such as delusions of grandeur.

Major depressive disorder involves persistent sadness, hopelessness, and loss of interest. Psychotic features can occur in severe depression, but the specific delusion of being Jesus is more consistent with schizophrenia.

Using an interpreter to obtain health information during an assessment is appropriate when language barriers exist. It ensures accurate communication, prevents misunderstandings, and promotes patient safety. Professional interpreters are preferred over family members to maintain confidentiality and accuracy.

Maintaining eye contact is often considered respectful in many cultures, but nurses must be sensitive to cultural variations. In some cultures, direct eye contact may be seen as disrespectful or confrontational. The nurse should assess the client’s comfort level and adapt accordingly. However, maintaining eye contact itself is not inherently wrong—it is the assumption of similarity that is problematic.

Supporting the client in participating in cultural and spiritual rituals demonstrates respect for cultural values and promotes holistic care. Encouraging such practices fosters trust, supports emotional well-being, and aligns with patient-centered care.