A female client, who is wearing dirty clothes and has a foul body odor, comes to the clinic reporting feeling scared because she is being stalked. What action is most important for the nurse to take?

Correct Answer: D

Rationale: The most important action for the nurse to take in this scenario is to offer the client a safe place to relax before interviewing her. The client's disheveled appearance and foul body odor suggest she may be in distress or facing challenging circumstances. By providing her with a safe and comfortable environment to relax, the nurse can help alleviate some of her distress and establish trust. This approach is crucial as the client is already feeling scared due to being stalked, indicating underlying mental health concerns. Assuring the client of a healthcare provider visit (choice A) may not address her immediate need for safety and comfort. Recommending she talk with a social worker (choice B) may be beneficial later but does not address the immediate need for a safe space. Asking the client to describe why she is being stalked (choice C) is not appropriate as the priority is ensuring her safety and comfort first.

Correct Answer: B

Rationale: In mental health nursing, understanding defense mechanisms is crucial for assessing and supporting clients. In this scenario, option B demonstrates the defense mechanism of projection. The client is attributing their own unacceptable thoughts or feelings (violence towards the aide) to someone else (hitting the wall), avoiding personal responsibility and projecting their feelings onto another. Option A reflects the defense mechanism of rationalization, where the client justifies their behavior by externalizing blame onto the police. Option C reflects denial, as the client is refusing to acknowledge their true feelings about being in the psychiatric facility. Option D demonstrates the defense mechanism of denial and possibly blame shifting, as the client is negating their family's concerns and attempting to discredit them. Educationally, this question helps students understand how defense mechanisms manifest in client statements during stressful situations. It reinforces the importance of recognizing these mechanisms to provide appropriate therapeutic interventions and support for clients dealing with anxiety and distress.

Correct Answer: A

Rationale: The correct answer is A. This statement indicates a lack of understanding about medication management for schizophrenia. Medications for schizophrenia should be taken consistently as prescribed for optimal effectiveness, regardless of how the client feels. Choice B is a correct statement as regular follow-up with a psychiatrist is important for monitoring progress and adjusting treatment. Choice C demonstrates good awareness of potential side effects and the need for communication with healthcare providers. Choice D reflects appropriate knowledge as alcohol can interact with medications and may reduce their effectiveness.

Correct Answer: B

Rationale: The correct answer is an electrolyte panel. When a client presents with confusion, disorientation, and agitation after drinking alcohol, it indicates potential complications such as electrolyte imbalances. Monitoring electrolyte levels is crucial in these cases to detect and address abnormalities that may result from alcohol intake. While a complete blood count (choice A) may provide some valuable information, it is not the primary test to assess for alcohol-related complications presenting with these symptoms. Liver function tests (choice C) are more specific for assessing liver damage due to chronic alcohol use rather than immediate complications. Urinalysis (choice D) may help detect some issues but is not the most appropriate initial test to assess for potential complications in this scenario.

Correct Answer: C

Rationale: In an elderly client with major depressive disorder, disorganized speech and thought processes are the most concerning assessment finding for the nurse. These symptoms can suggest a more severe condition such as psychosis or cognitive impairment, which require immediate attention and intervention. Weight loss, lack of interest in activities, severe fatigue, and low energy levels are common symptoms of major depressive disorder but do not pose an immediate risk as disorganized speech and thought processes do.