Choice A rationale

Interviewing the child about suspected abuse with a parent present could compromise the investigation and potentially endanger the child further. The parent, if the abuser, might intimidate or coach the child, preventing the disclosure of crucial information. A private, safe environment is necessary for the child to speak freely.

Choice B rationale

Completing an incident report for risk management is an important internal administrative step for the healthcare facility. However, it does not fulfill the legal and ethical obligation to report suspected child abuse to the appropriate external authorities who can initiate an investigation and ensure the child's safety.

Choice C rationale

Informing the parents that the findings must be reported to authorities might alert a potential abuser and could lead to further harm or the destruction of evidence. The priority is the child's safety, and direct reporting to the appropriate agency is the necessary first step.

Choice D rationale

Reporting suspected child abuse to the appropriate child protective services agency is the mandated legal and ethical responsibility of healthcare professionals. A perforated eardrum in a school-age child, especially if the explanation is inconsistent with the injury, raises suspicion of non-accidental trauma and requires immediate reporting to ensure the child's safety and well-being.

Choice A rationale

Keeping the client's room dark at night can worsen delirium by reducing environmental cues and potentially increasing disorientation and fear. Clients with delirium benefit from a well-lit environment that helps them maintain a sense of reality and reduces the risk of misinterpreting stimuli.

Choice B rationale

Limiting the client's need to make decisions can decrease their sense of control and autonomy, potentially increasing agitation and frustration associated with delirium. While simplifying choices is helpful, completely eliminating decision-making can be counterproductive to their engagement and orientation.

Choice C rationale

Discouraging visitation from the client's family can increase the client's feelings of isolation and anxiety, which can exacerbate delirium. Familiar faces and voices can provide comfort and reassurance, aiding in orientation and reducing agitation.

Choice D rationale

Providing a consistent daily routine helps to orient the client with acute delirium to time and place, reducing confusion and anxiety. Predictable patterns of activity, such as meals, hygiene, and rest, offer structure and familiarity, which can stabilize cognitive function and promote a sense of security.

Choice A rationale

Increased sleep can sometimes be associated with depression, which can co-occur with schizophrenia, but it is not a primary indicator of relapse of psychotic symptoms. Relapse typically involves an exacerbation of positive symptoms like hallucinations or delusions.

Choice B rationale

Obsession with hygiene rituals is more commonly associated with obsessive-compulsive disorder (OCD), which can be a comorbid condition in individuals with schizophrenia but is not a direct indicator of a psychotic relapse. While changes in behavior should be noted, this specific manifestation is less indicative of worsening schizophrenia.

Choice C rationale

Excessive appetite can be a side effect of certain antipsychotic medications or related to other factors, but it is not a core manifestation of a relapse of schizophrenia. Changes in appetite can occur, but increased suspiciousness is a more direct indicator of worsening psychotic symptoms.

Choice D rationale

Increased suspiciousness, paranoia, and mistrust are hallmark negative symptoms and often early indicators of a psychotic relapse in individuals with schizophrenia. Heightened suspicion can precede the return of more overt psychotic symptoms like hallucinations or delusions, signaling a destabilization of their mental state.

Choice A rationale

Consuming red wine before bed, even in small amounts, can disrupt sleep architecture. While alcohol might initially induce drowsiness, it often leads to fragmented sleep later in the night as the body metabolizes it, resulting in poor sleep quality and reduced restorative sleep.

Choice B rationale

Staying in bed for prolonged periods when unable to sleep can create a negative association between the bed and wakefulness. This can increase anxiety about sleep and perpetuate insomnia. It is generally recommended to get out of bed and engage in a relaxing activity until feeling sleepy.

Choice C rationale

Exercising vigorously close to bedtime can be stimulating and raise core body temperature, making it harder to fall asleep. The body needs time to cool down for optimal sleep initiation. It is generally recommended to avoid intense exercise at least a few hours before bed.

Choice D rationale

Caffeine is a stimulant that can interfere with sleep initiation and maintenance. Limiting caffeine intake, especially in the afternoon and evening, can significantly improve sleep quality by reducing its stimulating effects on the central nervous system. Normal caffeine intake should be limited, and eliminating it closer to bedtime is beneficial for sleep.

Choice A rationale

Liver enzymes (such as ALT and AST) are primarily monitored for medications known to cause liver toxicity. While lithium can have various side effects, it is not typically associated with significant liver damage requiring routine monitoring of liver enzyme levels. Normal ranges for ALT are typically 7 to 55 units per liter (U/L) for men and 5 to 40 U/L for women, and for AST are typically 10 to 40 U/L for men and 9 to 32 U/L for women.

Choice B rationale

Lithium is a mood stabilizer with a narrow therapeutic range, and its levels are closely linked to sodium balance in the body. Hyponatremia (low sodium levels) can increase the risk of lithium toxicity because the kidneys reabsorb lithium in an attempt to compensate for the sodium loss. Therefore, regular monitoring of serum sodium levels is crucial to ensure lithium remains within the therapeutic range (typically 0.6 to 1.2 mEq/L for maintenance) and to prevent toxicity. Normal serum sodium levels are generally 135 to 145 mEq/L.

Choice C rationale

Uric acid levels are primarily monitored in conditions like gout or kidney disease, or as a side effect of certain medications affecting purine metabolism. Lithium does not typically have a significant impact on uric acid levels requiring routine monitoring. Normal uric acid levels are typically 3.5 to 7.2 mg/dL for men and 2.6 to 6.0 mg/dL for women.

Choice D rationale

Erythrocyte sedimentation rate (ESR) is a non-specific marker of inflammation in the body. While lithium can have various effects, it is not typically associated with significant changes in ESR that would necessitate routine monitoring. Normal ESR values are generally 0 to 15 mm/hr for men and 0 to 20 mm/hr for women. .

Choice A rationale

While a bruise on the shin could indicate abuse, it could also result from an accidental bump or fall, which are common in older adults due to factors like impaired balance or decreased bone density. A single bruise alone is not definitive evidence of caregiver abuse or neglect and requires further assessment to determine the cause.

Choice B rationale

Being 9 kg (20 lb) over the recommended weight is indicative of potential overeating or a sedentary lifestyle, both of which are health concerns but not direct indicators of caregiver abuse or neglect. Weight management is related to dietary habits and physical activity levels, not necessarily the actions of a caregiver.

Choice C rationale

A caregiver paying a client's bills is not necessarily indicative of abuse or neglect. It could be a sign of assistance and support, especially if the client has difficulty managing their finances. Financial arrangements between a client and caregiver need to be assessed within the context of their relationship and the client's capacity.

Choice D rationale

Wearing soiled clothing suggests a lack of proper hygiene and care, which could be a sign of neglect by the caregiver. Inadequate attention to basic needs like cleanliness can lead to skin breakdown, infections, and a decline in the client's overall health and well-being. This warrants further investigation into the care provided.

Choice A rationale

Engaging in regular physical activity helps to reduce the physiological effects of chronic stress by releasing endorphins, which have mood-boosting and pain-relieving effects. Exercise also improves cardiovascular health, reduces muscle tension, and promotes better sleep, all of which are negatively impacted by prolonged stress.

Choice B rationale

Consuming a moderate amount of caffeine can provide a temporary boost in alertness and energy; however, it can also exacerbate anxiety, interfere with sleep patterns, and increase heart rate, potentially worsening the physiological symptoms of chronic stress in the long run. Its effects are highly individual.

Choice C rationale

Limiting exercise close to bedtime is important because physical activity stimulates the body and can make it harder to fall asleep. Engaging in exercise too close to sleep can elevate heart rate and body temperature, counteracting the body's natural preparation for rest. It is generally recommended to finish strenuous activity at least a few hours before sleep.

Choice D rationale

Aiming for approximately 7-9 hours of sleep per night is crucial for managing chronic stress. Adequate sleep allows the body and mind to recover, improves mood regulation, enhances cognitive function, and strengthens the immune system, all of which are compromised by chronic stress and essential for resilience.

Choice A rationale

While exploring the client's relationship with their partner is important for understanding their grief, immediately asking for details might feel intrusive or overwhelming shortly after a significant loss. The nurse should first acknowledge the client's feelings before delving into specifics of the relationship.

Choice B rationale

"Grief affects everyone differently; your feelings are valid" is an empathetic and validating response that acknowledges the client's unique experience and normalizes their emotions. It provides support and reassurance without minimizing their loss or telling them how they should feel, fostering trust and open communication.

Choice C rationale

Suggesting the client "stay busy to take your mind off things" can be dismissive of their grief and may prevent them from processing their emotions in a healthy way. While distraction can be helpful at times, avoiding grief entirely is not a constructive coping mechanism and can prolong the healing process.

Choice D rationale

Recommending a bereavement support group is a helpful suggestion for long-term support; however, immediately after the loss, the client may not be ready to engage in a group setting. The nurse should first focus on providing immediate emotional support and then suggest resources like support groups when the client is more ready.

Choice A rationale

Access to firearms in the home significantly increases the risk of suicide because firearms are highly lethal and provide a quick and often impulsive means of ending one's life. The availability of a firearm reduces the time between suicidal ideation and action, making intervention more difficult.

Choice B rationale

A sibling history of suicide can increase an individual's risk due to potential genetic predispositions to mental health disorders or learned behaviors and coping mechanisms within the family. However, it is not as direct or immediate a risk factor as other factors.

Choice C rationale

Being currently unmarried can be a contributing factor to social isolation and lack of support, which are risk factors for suicide. However, marital status alone is not a strong predictor of suicide risk, as many unmarried individuals have strong social networks, and married individuals can still experience isolation.

Choice D rationale

Expressing feelings of hopelessness is a critical warning sign for suicide. Hopelessness is a state of despair where an individual believes their situation will never improve, leading to a sense of futility and a higher likelihood of considering suicide as an escape.

Choice E rationale

A recent significant loss, such as the death of a loved one, a job loss, or the end of a significant relationship, can trigger intense emotional distress and increase vulnerability to suicidal ideation, especially if the individual lacks adequate coping mechanisms or social support. .

Choice A rationale

Seeking out a staff member during urges to self-harm demonstrates the effectiveness of a verbal safety contract. This behavior indicates the client is adhering to the agreement by reaching out for support instead of acting on the urges, signifying an increased ability to manage self-destructive impulses through communication and engagement with the treatment team.

Choice B rationale

Spending time alone when experiencing overwhelming feelings might indicate avoidance rather than effective coping. While some alone time can be therapeutic, relying solely on isolation could prevent the client from practicing new coping skills and engaging with support systems, potentially undermining the safety contract's goal of seeking help.

Choice C rationale

Avoiding discussion of difficult emotions with the treatment team suggests a lack of trust or engagement in the therapeutic process. An effective safety contract relies on open communication about feelings and urges to ensure the client receives timely support and can work through difficult emotions in a safe environment.

Choice D rationale

Attempting to suppress feelings of anger and frustration is an unhealthy coping mechanism. Suppressing emotions can lead to a buildup of internal tension, potentially increasing the likelihood of acting on self-harm urges. A safety contract aims to help the client identify and express emotions in constructive ways, not suppress them.