Correct Answer: A

Rationale: Establishing rapport is the most important action during the initial interview for a client admitted to the mental health unit. Building rapport helps create a trusting relationship between the nurse and the client, which is essential for effective communication and the success of the therapeutic relationship. Choice B, determining the client's ability to communicate effectively, is important but secondary to establishing rapport. Choice C, reflecting on previous psychiatric interviews, is not as critical during the initial interview with a new client. Choice D, ensuring data collection and recording in a systematic sequence, is important but comes after establishing rapport to foster a therapeutic environment.

Correct Answer: C

Rationale: Redirecting the client to a less confusing environment can help reduce anxiety and reorient her to reality.

Correct Answer: C

Rationale: The most appropriate response is 'I am here to help you just like the other nurses' (C). This response sets boundaries and avoids reinforcing the client's splitting behavior, which is common in borderline personality disorder. Choices A and D may unintentionally reinforce the splitting by focusing on the negative perception of other nurses. Choice B might be perceived as dismissive because it contradicts the client's feelings of being understood only by the nurse.

Correct Answer: B

Rationale: The correct answer is B. Increased energy without improvement in mood can increase the risk of self-harm in clients with depression. It is crucial for the nurse to recognize this potential risk and closely monitor the client for any signs of self-harm. Choice A is incorrect because dismissing the client's persistent feelings of sadness and hopelessness as normal may invalidate her experiences. Choice C is incorrect as fluoxetine (Prozac) typically starts showing effectiveness within a few weeks, so further delay is concerning. Choice D is incorrect because while discussing the client's feelings is important, the immediate focus should be on addressing the potential risk of self-harm associated with increased energy.

Correct Answer: B

Rationale: The correct answer is B: "Nausea is a common side effect of sertraline, and clients should be reassured that it usually decreases as their body adjusts to the medication." Choice A is incorrect because abruptly stopping the medication without consulting a healthcare provider can be harmful. Choice C is a good suggestion to reduce nausea by taking the medication with food but does not address the temporary nature of the side effect. Choice D is unnecessary at this point since nausea is a common side effect that may improve with time.