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: B

Rationale: Loss of appetite is not a specific manifestation of lithium toxicity. However, gastrointestinal symptoms like nausea and vomiting can contribute to a decreased appetite. Vomiting and diarrhea. Lithium is a mood stabilizer commonly used in the treatment of bipolar disorder.
Toxicity can occur, and symptoms can range from mild to severe. Vomiting and diarrhea are common early signs of lithium toxicity. As toxicity progresses, it can lead to more severe symptoms, such as tremors, confusion, and potentially life-threatening complications. Increased flatulence is not a typical manifestation of lithium toxicity. Gastrointestinal symptoms associated with lithium toxicity are more likely to include nausea, vomiting, and diarrhea. Increased urination is not a typical manifestation of lithium toxicity. Lithium can affect renal function, leading to decreased urine output, but it does not typically cause increased urination as a sign of toxicity.

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is experiencing negative symptoms related to their schizophrenia are: B. Lack of motivation; D. Lack of energy; E. Withdrawn.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: C

Rationale: Everyone has trouble sleeping at times' minimizes the client's concerns and may not address the underlying issues contributing to their anxiety. 'Why do you think you are so anxious?' might come across as judgmental or confrontational, and it may not create a supportive environment for the client to open up about their feelings. 'Have you talked to your provider about this yet?' This response encourages the client to seek professional help and addresses the issue of increasing anxiety and difficulty sleeping. It is supportive and guides the client toward discussing their concerns with a healthcare provider who can assess the situation and provide appropriate interventions. 'It sounds like you're having a difficult time' acknowledges the client's distress but does not guide them toward seeking professional help. Encouraging a conversation with a healthcare provider is a more direct and helpful approach.

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].