A client is admitted to the mental health unit and sits in the corner of the dayroom. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. What action should the nurse implement?

Correct Answer: A

Rationale: The correct action for the nurse to implement is to attempt to ask the client simple questions (Choice A). By asking simple questions, the nurse can start building rapport with the client and gradually gain their trust. This approach can help the client feel more comfortable and open up during the assessment interview. It is important for the nurse to demonstrate patience, empathy, and understanding towards the client's guarded and suspicious behavior. Postponing the client interview until the next day (Choice B) may not address the client's current needs and may lead to further distrust. Asking another nurse to talk with the client (Choice C) may not necessarily be effective as the client may benefit from continuity of care with the same nurse. Documenting the client's paranoid behavior (Choice D) is important for the client's medical record but should not be the only action taken by the nurse in this situation.

Correct Answer: A

Rationale: Step 1: The symptoms of diarrhea, vomiting, and drowsiness are potential signs of lithium toxicity. Step 2: Nurse should prioritize safety and inform the healthcare provider (HCP) immediately to adjust the treatment plan. Step 3: Delaying the next dose could prevent further toxicity and potential harm to the client. Step 4: Administering an antiemetic or encouraging fluids may not address the underlying issue of lithium toxicity. Step 5: Documenting the symptoms as expected side effects without taking immediate action could lead to serious consequences.

Correct Answer: A

Rationale: The correct answer is A because Risperidone is an atypical antipsychotic that primarily works by blocking dopamine and serotonin receptors in the brain, which helps to reduce hallucinations, delusions, and other psychotic symptoms. This mechanism of action does not directly relate to improving thinking clarity, reducing anxiety, stabilizing mood, or improving sleep, making options B, C, and D incorrect.

Correct Answer: D

Rationale: The correct answer is D because the most crucial goal for a client with major depression on antidepressants is to ensure their safety and prevent self-harm. Monitoring for suicidal ideation and behavior is a top priority. Ventilating feelings of sadness (A) is important but not as critical as ensuring safety. Eating three meals a day (B) and participating in group meetings (C) are important for overall well-being but do not directly address the immediate safety concern of potential suicide attempts.

Correct Answer: A

Rationale: The correct answer is A: Teach him to limit sugar and caffeine intake. This is the best option as excessive sugar and caffeine consumption can worsen anxiety symptoms. By reducing intake, it can help stabilize mood and energy levels. Choice B of encouraging a vacation may provide temporary relief but does not address the root cause of anxiety. Choice C of recommending financial counseling focuses solely on the financial aspect, not the physical factors contributing to anxiety. Choice D of administering PRN antianxiety medication should be a last resort and not the initial intervention.