At What Point Should the Nurse Determine That a Client

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

A) When thoughts, feelings, and behaviors are not reflective of the DSM-5 criteria.
B) When maladaptive responses to stress are coupled with interference in daily functioning.
C) When a client communicates significant distress.
D) When a client uses defense mechanisms as ego protection.