At what point should the nurse determine that a client is at risk for developing mental illness? When:

a client communicates significant distress.

maladaptive responses to stress are coupled with interference in daily functioning.

thoughts, feelings, and behaviors are not reflective of the DSM-5 criteria.

a client uses defense mechanisms as ego protection.

Answer and Explanation

The Correct Answer is B

a. a client communicates significant distress. While significant distress is important to consider, it alone does not necessarily indicate a risk for developing mental illness unless it also impacts daily functioning and coping mechanisms.
b. maladaptive responses to stress are coupled with interference in daily functioning. This choice is correct because it reflects a combination of maladaptive coping (which can exacerbate mental health issues) and interference with daily functioning (a key indicator of mental illness according to DSM-5 criteria).
c. thoughts, feelings, and behaviors are not reflective of the DSM-5 criteria. While alignment with DSM-5 criteria is crucial for diagnosis, this choice alone does not address the risk aspect. The focus should be on behaviors that lead to impairment in daily functioning and coping.
d. a client uses defense mechanisms as ego protection. Using defense mechanisms is a normal part of human behavior and not necessarily indicative of mental illness risk unless these mechanisms are maladaptive and interfere with functioning.

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Correct Answer is C

Explanation

a. "I am less likely to get an infection while taking this medication." This statement is incorrect. Chlorpromazine can actually increase the risk of infection due to potential side effects like agranulocytosis (a drop in white blood cell count).
b. "Weight loss is a sign that my medication dose is too low." This statement is incorrect. Chlorpromazine typically causes weight gain rather than weight loss.
c. "I will contact my healthcare provider if I have difficulty urinating." This statement indicates an understanding of one of the potential side effects of chlorpromazine, which can cause urinary retention due to its anticholinergic properties.
d. "I will stop taking this medication once my hallucinations go away." This statement is incorrect. Discontinuing antipsychotic medication without a healthcare provider's guidance can lead to a relapse of symptoms.

A. Establish rapport and develop treatment goals. B. Acknowledge the client's actions, and generate alternative behaviors. C. Explore how thoughts and feeling about this client may adversely impact nursing care. D. Attempt to find alternative placement.

Correct Answer is A

Explanation

a. Establish rapport and develop treatment goals: During the orientation phase, the primary focus is on building trust and rapport with the client. Establishing rapport and developing treatment goals are essential to creating a therapeutic alliance and setting the stage for effective treatment.
b. Acknowledge the client's actions, and generate alternative behaviours: This action is more appropriate during the working phase, where the nurse and client work on behavior change and coping strategies.
c. Explore how thoughts and feelings about this client may adversely impact nursing care: This is part of the nurse's self-reflection and supervision but is not the priority during the orientation phase.
d. Attempt to find alternative placement: This may be considered if the current setting is unsuitable, but it is not the primary focus of the orientation phase.

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At what point should the nurse determine that a client is at risk for developing mental illness? When:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with schizophrenia is receiving teaching from the nurse about their prescribed medication, Chlorpromazine. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is C

Explanation

What should be the priority nursing action during the orientation (introductory) phase of the nurse-client relationship?

Correct Answer is A

Explanation

The nurse is interviewing a newly admitted client. Which of the following nursing statements is an example of offering a "general lead"?

A client has recently been diagnosed with Alzheimer's disease. Which medication would the nurse expect the physician to order for this client's cognitive impairment?

Parents ask a nurse how they should reply when their child, diagnosed with schizophrenia disorder, tells them that voices command the child to harm others. Which is the appropriate nursing response?

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