Correct Answer: D

Rationale: The client's statement of not wanting to talk and feeling that nothing matters anymore is indicative of severe depression or a risk for self-harm. This warrants immediate attention and one-on-one observation to ensure the client's safety. Choices A, B, and C do not express the same level of concerning behavior and do not imply an immediate risk to the client's well-being.

Correct Answer: C

Rationale: The nurse is responsible for maintaining a therapeutic milieu in an inpatient setting, which involves creating a secure and structured environment that promotes client safety and offers opportunities for clients to learn healthy coping skills. Regularly scheduled unit activities for peer interaction help foster socialization, support, and a sense of community among clients. Choices A and B are valuable interventions in mental health care but do not directly relate to creating a therapeutic milieu in an inpatient setting. Choice D, home visits, would typically occur post-discharge and focus on community reintegration, rather than maintaining a therapeutic milieu within the inpatient setting.

Correct Answer: D

Rationale: In this scenario, the most critical question for the RN to ask the client relates to hallucinations. Hallucinations, such as hearing sounds or voices others do not hear, are a hallmark symptom of schizophrenia. This inquiry is vital for assessing the presence of psychotic symptoms and the potential relapse of the client's condition. Choices A, B, and C, although important in assessing overall mental health, do not directly address the core symptomatology of schizophrenia or the potential impact of discontinuing antipsychotic medication abruptly.

Correct Answer: B

Rationale: Establishing trust by providing a calm and safe environment is crucial for the success of desensitization therapy in clients with agoraphobia. This approach helps the client feel safe and secure, allowing them to gradually confront their fear of crowds. Encouraging positive thoughts (choice A) is beneficial but not as immediately critical as creating a safe space. Progressively exposing the client to larger crowds (choice C) should occur after trust is established and in a controlled manner. Encouraging deep breathing (choice D) is helpful, but creating a safe environment takes precedence to build a foundation for successful desensitization.

Correct Answer: C

Rationale: The question 'How do you feel about talking to a mental health counselor?' is the most appropriate to assess the teenager's mental health resilience as it directly addresses their willingness to seek help and cope effectively. Choices A and B focus on coping mechanisms during a specific event, which may not reflect the teenager's overall resilience. Choice D is more related to future aspirations rather than assessing current mental health resilience.