At which point would the nurse determine that a client is at risk for developing a mental illness?

Correct Answer: B

Rationale: Step 1: Identify the key indicators for risk of mental illness - maladaptive responses to stress and interference in daily functioning. Step 2: Understand that maladaptive responses and interference in daily functioning are strong indicators of potential mental illness. Step 3: Recognize that these factors signify a disruption in the client's ability to cope effectively. Step 4: Differentiate from other choices - A focuses on DSM-5 criteria, C on distress communication, and D on defense mechanisms. Step 5: Summary: Choice B is correct because it directly addresses the core indicators of risk for mental illness, while the other choices do not directly relate to this specific risk factor.

Correct Answer: C

Rationale: The correct answer is C: At 11 pm. This is based on the prescription stating the medication should be given every 6 hours. You administered the first dose at 5 pm, so the next dose should be given 6 hours later at 11 pm. Choices A and B are incorrect because medication administration should be based on the prescribed schedule, not solely on patient request or pain level. Choice D, at 12 pm, is incorrect as it does not align with the 6-hour dosing interval specified in the prescription.

Correct Answer: B

Rationale: Correct Answer: B - Verify patient identification and informed consent Rationale: 1. Ensures the right patient is undergoing the intended procedure. 2. Validates patient's understanding and agreement to the procedure. 3. Legal and ethical requirement to prevent errors and ensure patient safety. Summary: A: Important but assessing consciousness can be done after patient identification. C: Vital signs are crucial but can be assessed after verifying patient identity. D: Checking for personal items is important but secondary to confirming patient identity.

Correct Answer: C

Rationale: The correct answer is C: Wash hands. This is the first step in any nursing intervention to prevent infection. Washing hands before examining the incision wound and changing the dressing helps reduce the risk of introducing harmful bacteria. By washing hands, the nurse maintains aseptic technique and minimizes the chance of contaminating the wound. Choice A is incorrect because observing the dressing and drainage comes after washing hands to ensure a clean environment. Choice B is unnecessary for a routine wound dressing change. Choice D is incorrect because requesting the client to expose the wound should only be done after ensuring proper hand hygiene.

Correct Answer: C

Rationale: The correct answer is C because allowing the client to walk relative to the Operating Room (OR) would increase the risk of falls, contradicting the goal of reducing patient harm. Walking near the OR could lead to accidents due to medical equipment, slippery floors, or unfamiliar surroundings. Assessing potential fall risks related to medications (choice A) is crucial for identifying and mitigating risks. Taking action through Incident Reports (choice B) helps address identified risks and improve patient safety. Assessing and reassessing individual fall risks (choice D) is essential for tailoring preventive measures to each patient's needs. In summary, allowing clients to walk near the OR poses a significant risk of falls and should be avoided.