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A Nurse Is Caring for a 25-Year-Old Client with No

Question 16

Multiple Choice

A nurse is caring for a 25-year-old client with no previous history of mental illness. The client is admitted to the mental healthcare unit demonstrating psychotic behaviors. Which mental health intervention should the nurse implement first?


A) Monitor of signs/symptoms of alcohol or drug withdrawal.
B) Document any unusual occurrences, such as injuries or altercations.
C) Check for overuse of defense mechanisms in the client.
D) Observe if the person has unprovoked bursts of temper.

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