A. Clients with major depressive disorder often exhibit decreased response to stimuli rather than an exaggerated response.
B. Weight changes, either a significant gain or loss, are common in individuals with major depressive disorder due to changes in appetite.
C. Hyperexcitability is not typically associated with major depressive disorder. Instead, individuals with depression often exhibit decreased energy and enthusiasm.
D. While seeking attention can manifest in some individuals with mental health conditions, it's not a defining characteristic of major depressive disorder.

A. While social support is essential, sudden changes in behavior warrant assessment and understanding before taking the client outside the facility.
B. Monitoring might be necessary but does not directly address the reason behind the sudden change in behavior.
C. This approach may reinforce the behavior without addressing the underlying cause.
D. This intervention is crucial for assessment and understanding the sudden shift in the client's mood, which could provide insight into the effectiveness of the treatment or other factors contributing to the change.

A. This statement refers to the "duty to warn," a legal obligation to protect third parties if a client expresses a serious threat of harm to others. It's a crucial exception to confidentiality.
B. This statement is inaccurate as there are scenarios where healthcare workers are legally required to provide information to the court.
C. This statement is not entirely accurate; there are legal boundaries and requirements for disclosing client information to attorneys.
D. Confidentiality extends even after a client's death in many situations, but there are exceptions based on state laws and ethical guidelines.

A. Experiencing a life-threatening event such as being trapped can precipitate PTSD.
B. Exposure to an R-rated movie, while potentially distressing, is not typically considered a traumatic event that leads to PTSD.
C. Prolonged exposure to traumatic events like abduction and captivity often leads to PTSD due to the severe and chronic trauma experienced.
D. This is not typically considered a traumatic event leading to PTSD as it's a voluntary, recreational activity that involves perceived safety measures.

A. While assessing depression is crucial, in a situation following a suicide attempt, the immediate safety of the client takes precedence.
B. While ensuring the client's nutrition is important, safety regarding the recent suicide attempt is the priority.
C. This is relevant to the situation but doesn't directly address the immediate risk of self-harm or suicide.
D. Given the client's history of a suicide attempt and the present situation, initiating measures to ensure the client's safety and prevent any further harm, such as suicide precautions, is the priority.

Rationale for A: Inviting a family member to be present may hinder communication, especially if the family member is involved in the abuse or the client feels unsafe speaking in their presence. Privacy is crucial for encouraging open communication.

Rationale for B: Providing basic wound care is important for physical injuries, but it does not directly address promoting communication. The nurse should focus on creating a safe environment for the client to talk.

Rationale for C: Being direct and honest when speaking with the client promotes trust and open communication. Clients who are suspected of being abused may be fearful or reluctant to share information, so clear, respectful communication helps create a supportive environment.

Rationale for D: Probing the client for a factual account of the abuse may make the client feel pressured or overwhelmed. The nurse should allow the client to share information at their own pace without feeling forced to disclose details.

A. This statement reflects concern about a potential cause of a birth defect, not necessarily PTSD symptoms.
B. This statement indicates recurrent nightmares, a potential symptom of PTSD, but it doesn't involve the persistent feeling of threat.
C. This statement reflects hypervigilance and persistent feelings of threat, a common symptom of PTSD.
D. While this statement might be related to combat experience, it doesn't necessarily indicate PTSD.

A. This precaution helps eliminate potential means for self-harm.
B. Regular checks and verbal contact are essential to monitor the patient's safety and provide support.
C. Removing objects that could be used for self-harm is a key part of suicide precautions.
D. While this is an intensive level of observation, it might not be feasible at all times due to staffing limitations, making this choice less practical than the others.

A. This statement demonstrates the nurse's willingness to spend time with the patient to build rapport and trust, offering the nurse's presence and support.
B. This statement expresses hope but doesn't directly offer the nurse's presence or support.
C. This question encourages exploration of the patient's feelings but doesn't directly offer the nurse's presence.
D. This statement shares personal experiences but doesn't directly offer the nurse's presence or support.

A: Demonstrating empathy would involve acknowledging the client's feelings or beliefs, but the nurse does not validate the client's delusion or express understanding of the client's emotional state. Instead, the nurse redirects the client to the reality of the situation, which is the group therapy session.

B: The nurse's response is therapeutic because it clearly communicates the expectations of the therapy environment. By stating "it is time for group therapy and we expect everyone to attend," the nurse is providing clear, structured guidance without engaging with the delusion, which can help the client understand the reality of the situation and what is required of them.

C: Setting limits on manipulative behavior would involve addressing and curtailing attempts by the client to control or influence a situation for their own benefit. In this scenario, the client's behavior is delusional rather than manipulative, and the nurse's response does not directly set limits on manipulation but rather on adhering to the therapy schedule.

D: Using reflection would mean the nurse is mirroring the client's thoughts or feelings to help them self-reflect. However, the nurse does not reflect the client's statement but instead focuses on the expectations of the therapy program. The nurse's response does not encourage the client to reflect on their own thoughts or feelings but redirects them to the activity at hand.