Correct Answer: C

Rationale: Identification: Identification involves taking on the characteristics of another person, group, or entity. The client's response is not an example of identification. Relation-formation: This term is not a recognized defense mechanism in the context of classical psychoanalytic theory. It seems to be a combination of two concepts but doesn't fit the context of the client's statement. Projection: Projection is a defense mechanism where an individual attributes their own unacceptable thoughts, feelings, or impulses to another person. In this scenario, the client is projecting their own feelings of anger and a desire to have a drink onto the nurse and others, suggesting that the staff is angry at them and wants to go out for a drink. Compensation: Compensation involves making up for a perceived weakness by emphasizing a strength in another area. The client's statement do[es not fit this description].

Correct Answer: B,D,E

Rationale: The '3' findings that should indicate to the nurse that the client is experiencing negative symptoms related to their schizophrenia are: B. Lack of motivation; D. Lack of energy; E. Withdrawn. Negative symptoms in schizophrenia involve deficits or reductions in normal emotional and behavioral functioning. In the provided nurse's notes: Blood pressure: Blood pressure is not mentioned in the nurse's notes, and it is not directly indicative of negative symptoms in schizophrenia. B. Lack of motivation: The client refusing to eat or drink, not engaging in conversation, and not wanting to go to therapy sessions are indicative of a lack of motivation, which is a negative symptom. C. Change in behavior: While there is a change in behavior mentioned in the notes (refusing to eat or drink, not engaging in conversation), the specific behavioral changes described are more closely associated with negative symptoms. Negative symptoms involve a reduction or loss of normal functions. D. Lack of energy: The client's slow movements and desire to sleep suggest a lack of energy, another negative symptom associated with schizophrenia. E. Withdrawn: The client's withdrawal from social interaction, as evidenced by not engaging in conversation and wanting to sleep, is characteristic of withdrawal, which is a negative symptom.

Correct Answer: B

Rationale: Why do you think you are hearing the voices?' This question may come across as confrontational and might make the client defensive. It's better to focus on the content of the hallucinations rather than questioning the client's perception. 'What are the voices telling you to do?' This response is appropriate because it acknowledges the client's experience, shows empathy, and encourages the client to express their thoughts and feelings. It is important to gather more information about the content of the hallucinations and delusions to understand the client's perception of reality. 'You need to tell the voices to leave you alone.' This response oversimplifies the experience of hallucinations and may not be helpful. Telling the client to dismiss the voices is unlikely to be effective and may lead to frustration. 'You need to understand that there are no voices.' Denying the client's experience is not therapeutic. It's essential to validate the client's feelings and explore their subjective experience rather than dismissing it outright.

Correct Answer: C

Rationale: Foods that are high in dietary tyramine are more relevant to certain antidepressant medications, particularly monoamine oxidase inhibitors (MAOIs), and are not a specific concern with alprazolam. Increasing the dose of the medication without consulting the healthcare provider is not appropriate. Adjustments to the dosage should be done under the guidance of the healthcare provider. 'Avoid driving or operating heavy machinery until you know how alprazolam affects you.' This is an important safety consideration when using benzodiazepines such as alprazolam. Benzodiazepines can cause drowsiness and impair coordination, so clients should be advised to avoid activities that require mental alertness, such as driving or operating machinery, until they are aware of how the medication affects them. Manifestations of anxiety should improve with the use of alprazolam, and relief of symptoms can occur relatively quickly. However, it is essential to inform the client that long-term use of benzodiazepines may lead to tolerance and dependence. They should not abruptly stop the medication without consulting their healthcare provider.

Correct Answer: B

Rationale: A client taking olanzapine who experiences dizziness upon standing: While dizziness is a potential side effect, it is not as immediately concerning as the symptoms in the client taking clozapine. Orthostatic hypotension is a known side effect of some antipsychotic medications, and the client may need to be assessed for orthostatic changes. A client taking clozapine who has a sore throat and mild fever. Clozapine is an atypical antipsychotic that can cause agranulocytosis, a potentially life-threatening condition characterized by a severe reduction in white blood cell count. A sore throat and mild fever can be early signs of infection, and it's crucial to evaluate the client promptly for any indications of agranulocytosis. Regular monitoring of complete blood counts is essential for clients taking clozapine. A client taking risperidone who has gained 5 lb in 3 weeks: Weight gain is a side effect of many antipsychotic medications, including risperidone. While it's important to monitor weight changes, gaining 5 lb in 3 weeks is not as urgent as potential signs of agranulocytosis in the client taking clozapine. A client taking chlorpromazine who is napping frequently throughout the day: Frequent napping may be related to sedation, a common side effect of chlorpromazine. While it's important to assess and address sedation, it is not as urgent as potential signs of infection or agranulocytosis in the client taking clozapine.