Choice A reason:
An illusion is a misinterpretation of a real external stimulus. For example, seeing a shadow and thinking it is a person. The client’s statement does not indicate a misinterpretation of reality but rather a desire to inflict harm on themselves.
Choice B reason:
A hallucination is a false sensory perception without any real external stimulus, such as hearing voices or seeing things that are not there. The client’s statement does not suggest they are experiencing a hallucination but rather expressing a desire to self-harm.
Choice C reason:
Attention-seeking behavior involves actions taken to gain attention from others. While the client’s statement could be seen as a cry for help, it is more accurately identified as a risk for self-mutilation due to the explicit mention of wanting to cut themselves.
Choice D reason:
Self-mutilation refers to deliberate self-inflicted harm, often as a way to cope with emotional pain. The client’s statement, “Give me your pen to cut the pain out of my chest,” clearly indicates a risk for self-mutilation, as they are expressing a desire to harm themselves to alleviate emotional distress.

The correct answer is A.
Choice A reason:
An advance care directive, or “living will,” is a legal document that specifies what medical treatments the client wishes to receive or omit if they become unable to make decisions for themselves. This document guides healthcare providers and family members in making decisions that align with the client’s preferences.
Choice B reason:
A client is not required to sign the “living will” document with an attorney present. While it is advisable to consult with an attorney when creating legal documents, it is not a requirement for the validity of an advance care directive.
Choice C reason:
An attorney may assist in drafting the advance care directive, but it is not necessary for the attorney to draw up the papers. The client can create the document with the help of healthcare providers or legal advisors.
Choice D reason:
The client’s physician does not need to act as a witness when the client signs the document. Typically, witnesses are required to ensure the document is signed voluntarily and without coercion, but they do not have to be the client’s physician.

Choice A reason:
Agreeing to send the information without the client’s consent is a breach of confidentiality. Healthcare providers must protect patient privacy and cannot disclose medical information without explicit permission from the client.
Choice B reason:
While obtaining the client’s signed consent is necessary before releasing information, this response still acknowledges that the person in question is a client, which could be a breach of confidentiality.
Choice C reason:
Stating that the information cannot be given out is correct, but it still indirectly confirms that the person is a client, which could be a breach of confidentiality.
Choice D reason:
“I am unable to acknowledge whether or not your employee is a client on this unit” is the most appropriate response. This statement protects the client’s privacy by not confirming or denying their presence in the unit, thus maintaining confidentiality.

Choice A reason:
Countertransference occurs when a healthcare provider projects their own feelings and experiences onto the client. In this case, the nurse is responding to the client as if they were their grandparent, which indicates that the nurse’s personal feelings are influencing their professional relationship.
Choice B reason:
Empathy involves understanding and sharing the feelings of another person. While empathy is important in nursing, it does not involve projecting personal relationships onto the client.
Choice C reason:
Transference occurs when a client projects feelings about important figures in their life onto the healthcare provider. This is the opposite of countertransference, where the provider projects their feelings onto the client.
Choice D reason:
Modeling involves demonstrating behaviors for others to imitate. It does not describe the emotional reaction of projecting personal feelings onto a client.

Choice A reason:
Anhedonia, or the inability to experience pleasure, is a negative symptom of schizophrenia. Negative symptoms reflect a decrease or loss of normal functions and are often more challenging to treat than positive symptoms.
Choice B reason:
Hallucinations are positive symptoms of schizophrenia. Positive symptoms involve the presence of abnormal behaviors or experiences, such as hearing voices or seeing things that are not there.
Choice C reason:
Poor judgment is not classified as a negative symptom of schizophrenia. It can be a feature of cognitive impairment associated with the disorder but is not specifically a negative symptom.
Choice D reason:
Delusions are positive symptoms of schizophrenia. They involve false beliefs that are not based in reality, such as believing one has special powers or is being persecuted.
Choice E reason:
Blunt affect, or reduced emotional expression, is a negative symptom of schizophrenia. It involves a lack of emotional responsiveness and is indicative of the diminished capacity to express emotions.

Choice A reason:
Schizophrenia is rarely diagnosed in preschool-aged children. Early-onset schizophrenia can occur, but it is extremely uncommon in this age group.
Choice B reason:
While schizophrenia can develop in school-age children, it is still relatively rare. The typical age of onset is later, during adolescence or young adulthood.
Choice C reason:
Young adulthood is the most common age group for the onset of schizophrenia. Symptoms often begin to appear in late adolescence to early adulthood, typically between the ages of 16 and 30.
Choice D reason:
Schizophrenia is not typically diagnosed in older adulthood. While older adults can experience symptoms of schizophrenia, the onset of the disorder usually occurs much earlier in life.

Choice A reason:
Countertransference occurs when a healthcare provider projects their own feelings and experiences onto the client. In this case, the nurse is responding to the client as if they were their grandparent, which indicates that the nurse’s personal feelings are influencing their professional relationship.
Choice B reason:
Empathy involves understanding and sharing the feelings of another person. While empathy is important in nursing, it does not involve projecting personal relationships onto the client.
Choice C reason:
Transference occurs when a client projects feelings about important figures in their life onto the healthcare provider. This is the opposite of countertransference, where the provider projects their feelings onto the client.
Choice D reason:
Modeling involves demonstrating behaviors for others to imitate. It does not describe the emotional reaction of projecting personal feelings onto a client.

Choice A reason:
Asking “What are the voices telling you to do?” is an appropriate response because it allows the nurse to assess the content of the hallucinations and determine if the client is at risk of harming themselves or others. This approach shows empathy and concern while gathering important information for the client’s safety.
Choice B reason:
Telling the client “You need to understand that there are no voices” dismisses the client’s experience and can increase their distress. It is important to acknowledge the client’s feelings and perceptions, even if they are not based in reality.
Choice C reason:
Asking “Why do you think you are hearing the voices?” may not be helpful in the moment of distress. The client may not be able to provide a rational explanation for their hallucinations, and this question could increase their confusion and anxiety.
Choice D reason:
Telling the client “You need to tell the voices to leave you alone” may not be effective, as the client may not have the ability to control their hallucinations. It is more important to assess the content of the hallucinations and provide support.

Choice A reason:
Regression involves reverting to an earlier stage of development in response to stress. This defense mechanism is not indicated by Jake’s inability to recall specific details about his mother’s death.
Choice B reason:
Projection involves attributing one’s own unacceptable thoughts, feelings, or flaws to others. This defense mechanism does not explain Jake’s inability to remember details about his mother’s death.
Choice C reason:
Repression is a defense mechanism where distressing memories, thoughts, or feelings are unconsciously pushed out of conscious awareness. Jake’s inability to recall how old he was or the year his mother died suggests that he may be repressing these painful memories.
Choice D reason:
Suppression is a conscious effort to push distressing thoughts or feelings out of awareness. Since Jake is unable to recall specific details, it is more likely that repression, an unconscious process, is at play.

Choice A reason:
Implementation involves carrying out the interventions outlined in the care plan. This phase focuses on executing the planned actions to achieve the desired outcomes and does not include gathering initial information about the client’s history.
Choice B reason:
Evaluation involves assessing the effectiveness of the interventions and determining whether the goals of the care plan have been met. This phase occurs after the initial assessment and implementation of interventions.
Choice C reason:
Assessment is the first phase of the nursing process, where the nurse gathers comprehensive information about the client’s health status, including their family history of schizophrenia. This information is crucial for developing an accurate diagnosis and care plan.
Choice D reason:
Planning involves setting goals and determining the appropriate interventions based on the assessment data. While planning is essential, it follows the assessment phase and relies on the information gathered during the assessment.