A client with schizophrenia is experiencing auditory hallucinations. Which intervention should the nurse implement to address this symptom?

Correct Answer: C

Rationale: When a client with schizophrenia is experiencing auditory hallucinations, providing reality-based feedback is a therapeutic intervention. This helps the client differentiate between what is real and what is not, aiding in reducing the impact of hallucinations. Encouraging the client to discuss the voices may validate the hallucinations, telling the client that the voices are not real dismisses their experience, and distracting the client may not address the underlying issue of the hallucinations.

Correct Answer: C

Rationale: When assessing a client with moderate anxiety, the nurse should anticipate signs such as fidgeting, laughing inappropriately, and nail biting. These behaviors are common manifestations of increased stress levels. Palpitations, on the other hand, are more commonly associated with severe anxiety or panic attacks. Other symptoms of severe anxiety may include restlessness, difficulty concentrating, muscle tension, and sleep disturbances.

Correct Answer: D

Rationale: Cultural aspects of mental illness are shaped by societal norms, social structures, and community responses, influencing how behaviors are perceived, recognized, and treated. Let's examine each option step by step to identify which one does not align with established cultural patterns related to mental health. First, consider option A: "Local or cultural norms define pathological behavior." This is indeed a cultural aspect. In different cultures, what is considered "normal" or "pathological" varies significantly. For instance, in some Western societies, excessive individualism might be seen as a sign of confidence, while in collectivist cultures like those in parts of Asia, it could be viewed as antisocial or indicative of a mental disorder. Anthropological studies, such as those by Arthur Kleinman on neurasthenia in China, show how cultural idioms of distress redefine symptoms, making this a core way culture intersects with mental illness recognition. Next, option B: "The higher the social class, the greater the recognition of mental illness behaviors." This reflects a cultural aspect tied to socioeconomic hierarchies. In many societies, higher social classes have better access to education and healthcare, leading to greater awareness and labeling of mental health issues. Research from sociologists like Erving Goffman in "Asylums" highlights how class influences stigma and recognition; affluent individuals are more likely to seek professional help early, framing behaviors as illnesses rather than moral failings. Conversely, lower classes might attribute symptoms to supernatural causes, delaying recognition, which underscores class-based cultural differences in mental health perception. Then, option C: "Psychiatrists typically see patients when the family can no longer deny the illness." This is a cultural aspect rooted in family dynamics and denial mechanisms prevalent in many cultures. Families often act as the first line of support, interpreting odd behaviors through cultural lenses like spirit possession or stress before accepting medical intervention. In collectivist societies, such as in Latin America or South Asia, familial denial prolongs the time before professional psychiatric care is sought, as seen in studies on schizophrenia where community and family networks delay hospitalization until crises occur. This delay is a culturally mediated process, emphasizing relational harmony over individual pathology. Finally, option D: "The greater the cultural distance from the mainstream of society, the greater the likelihood that the illness will be treated with sensitivity and compassion." This is not a cultural aspect related to mental illness; in fact, it contradicts typical patterns. Marginalized or culturally distant groups—such as ethnic minorities, immigrants, or indigenous populations—often face heightened stigma, discrimination, and insensitive treatment. Sociological evidence from sources like the World Health Organization's reports on mental health disparities shows that those farther from the societal mainstream experience greater barriers, including misdiagnosis, coercive interventions, and lack of cultural competence from providers. For example, Native American communities might encounter treatments ignoring traditional healing practices, leading to less compassion rather than more. This option inverts the reality, where cultural distance usually correlates with reduced sensitivity due to prejudice and systemic biases, making it the incorrect statement about cultural aspects. In summary, A, B, and C accurately describe how culture influences the definition, recognition, and timing of mental illness interventions, while D misrepresents the common experience of marginalized groups, highlighting instead the need for cultural humility in mental health care.

Correct Answer: B

Rationale: During a mental status examination, components such as appearance and behavior, mood and affect, and cognitive function are assessed. Giving advice is not a component of a mental status examination as it focuses on evaluating the client's mental state rather than providing guidance or recommendations.

Correct Answer: D

Rationale: During alcohol withdrawal, the nurse should expect to observe symptoms such as tremors, hallucinations, and diaphoresis. Seizures may also occur during severe withdrawal. Bradycardia is not typically associated with alcohol withdrawal; instead, tachycardia (an increased heart rate) is more commonly observed due to the stimulant effects of alcohol withdrawal on the sympathetic nervous system.