Mental Health HESI 6

Mental Health HESI 6 Psychiatric Hesi book 1. A nurse working in the emergency department of a children's hospital admits a child whose injuries could have been the result of abuse. Which statement most accurately desc ...

Mental Health HESI 6 Psychiatric Hesi book 1. A nurse working in the emergency department of a children's hospital admits a child whose injuries could have been the result of abuse. Which statement most accurately describes the nurse's responsibility in cases of suspected child abuse? A. Obtain objective data such as radiographs before reporting suspicions. B. Confirm suspicions of abuse with the healthcare provider. C. Report any case of suspected child abuse. D. Document injuries to confirm suspected abuse. Rationale: It is the nurse's legal responsibility to report all suspected cases of child abuse (C), and notifying the nurse manager or charge nurse starts the legal reporting process. (A, B, and D) delay the first step in reporting the abuse. 2. An 8-year-old child is seen in the clinic with a green vaginal discharge. What action is most important for the nurse to implement? A. Assess the child's blood pressure. B. Counsel the child to wear cotton underwear. C. Report as suspected child abuse. D. Determine if the child takes bubble baths. Rationale: A green vaginal discharge is indicative of gonorrhea, a sexually transmitted disease. Since the child is 8 years old, the nurse should suspect child abuse and report the incident to the proper authorities (C). (A) is usually not related to infection. (B and D) are helpful in preventing bladder infections, but a green vaginal discharge is not a symptom of a bladder infection. 3. On admission, a highly anxious client is described as delusional. The nurse understands that delusions are most likely to occur with which disorder? A. Dissociative disorders B. Personality disorders C. Anxiety disorders D. Psychotic disorders Rationale: Delusions are false beliefs characteristic of psychosis (D). Delusions are generally not characteristic of (A, B, and C). 4. Over a period of several weeks, one male participant of a socialization group at a community daycare center for older adults monopolizes most of the group's time and interrupts others when they are talking. What is the best action for the nurse to take in this situation? A. Talk to him outside the group about his behavior. B. Ask him to give others a chance to talk. C. Allow the group to handle the problem. D. Ask him to join another group. Rationale: After several weeks, the group is in the working phase and the group members should be allowed to determine the direction of the group. The nurse should ignore the comments and allow the group to handle the situation (C). A good leader should not have separate meetings with group members (A), as such behavior is manipulative on the part of the leader. (B) is dictatorial and is not in keeping with good leadership skills. (D) is avoiding the problem. Remember, identify what phase the group is in (initial, working, or termination) as an aid to determining expected communication style. 5. A 22-year-old female client is admitted to the psychiatric unit from the medical unit following a suicide attempt with an overdose of diazepam (Valium). When developing the nursing care plan for this client, what intervention would be most important to include? A. Assist her to focus on her strengths. B. Set limits on her self-defacing comments. C. Remind her of daily activities in the milieu. D. Assist her to identify why she was self-destructive. Rationale: Encouraging the client to focus on her strengths (A) helps her become aware of her positive qualities, assists in improving her self-image, and aids her in coping with past and present situations. Although nursing actions should assist the client in decreasing (B) and inform the client of (C), these interventions are not a priority at this time. (D) is not as important as assisting her to overcome the depression, which resulted in the overdose, and asking "why" is nontherapeutic. 6. The nurse reviews the laboratory findings for a client's urine drug screen that is positive for cocaine. Which client behavior should be expected during cocaine withdrawal? A. Psychomotor impairment B. Agitation and hyperactivity C. Detachment from reality and drowsiness D. Distorted perceptions and hallucinations Rationale: During cocaine withdrawal, the nurse should expect (A) and a pattern of withdrawal symptoms similar to those of one who uses amphetamines. (B, C, and D) are signs and symptoms of a person who is high on cocaine rather than experiencing withdrawal from cocaine. 7. A 25-year-old client has suffered extensive burns and is crying during dressing change treatment. The client tells the nurse, "Please let me die. Why are you all torturing me like this? I just want to die." Which response by the nurse is best? A. "We aren't torturing you. These treatments are necessary to prevent a terrible infection." B. "I know these treatments must seem like torture to you, but we want to help you recover." C. "You have so much to live for, and all of your family members want you to live." D. "Would you like me to call the chaplain so that you can privately discuss your feelings?" Rationale: (B) offers an empathetic response without sounding patronizing. (A) is not empathetic and is actually somewhat argumentative. The client is not asking for information as much as pleading for understanding. (C) is almost scolding and places blame on the client for wanting to die and possibly hurting his family members as a result. (D) might be appropriate if the nurse simply asks the client if a chaplain's visit is desired, but the nurse is dismissing the client's needs by not addressing them at the moment. ........Continued