Psychiatric Mental Health Assignment Exam HESI Brand New 2023-2024| Guarantee Pass| Rated A+

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Psychiatric Mental Health Assignment Exam HESI Brand New 2023-2024| Guarantee Pass| Rated A+ A client is responding to auditory hallucinations and shakes a fist at a nurse and says, "Back off, wi... tch!" The nurse follows the client to the unit's day room. What action should the nurse implement? A. Sit down in a chair near the client. B. Position self within an arm's length of the client. C. Ensure that there is physical space between the nurse and client. D. Move to a position that allows the client to be closest to the room's door. Personal space should increase when a client feels anxious and threatened. An adequate social space (4 to 12 feet) between the nurse and the client should be maintained to minimize the client's escalation and physical contact with the nurse. The other positions increase the risk for injury if the client becomes aggressive. The nurse completes an emergency admission of a male client with schizophrenia who has not been taking his antipsychotic medications. The client is pacing, is extremely irritable, and has a blood pressure of 146/96. What is the priority nursing action? [Correct Ans:- Re-evaluate the client's blood pressure in an hour. The client is irritable and pacing, which can contribute to the elevated BP. A re-evaluation of the client's BP in an hour allows time for the excitement and stress of the admission process to abate. The other actions are not indicated at this time. A client who reports feeling depressed tells the nurse on admitted, "I want to feel normal again." How should the nurse respond? A. How long have you felt this way? B. We are all here to help you get better. C. What do you think the hospital can do for you? D. Tell me more about how things are with you. When a client offers psycho-emotional complaints as the reason for admission, open-ended statements that seek clarification and elaboration provide the nurse with information about the client's life experiences that helps the nurse empathize, establish rapport, and support the client while re-examining and expressing feelings. The other responses do not allow the client to vent and is not therapeutic. A client who abuses alcohol says to the nurse, "I am glad I went in for treatment. Now my problems with alcohol are all behind me." Which response is best for the nurse to provide? A. Yes, but do you know that the treatment program you attended has an excellent success profile? B. Tell me more about what you mean when you say that your problems with alcohol are now behind you. C. You are likely to have a difficult time staying sober if you think that problems with alcohol are behind you. D. Do you know what "one day at a time" means for those who have problems with alcohol? Those who attend alcohol treatment programs and Alcoholics Anonymous never put drinking problems behind them and describe alcoholics as only one step away from a slip with maintaining sobriety. The nurse should use reflection and encourage the client to further describe the feelings. The other responses do not encourage the client to reflect on his recovery. At the end of a group therapy session, a client who is hospitalized for psychosis falls to the floor when attempting to stand. What intervention should the nurse implement first? A. Ask a group member to seek help. B. Obtain the client's blood pressure. C. Position in a recovery position. D. Assess the client's level of orientation. First, help should be obtained while the nurse remains with the client. Next, assessment of the client should be completed. Lastly, the client should be positioned to prevent aspiration while recovering. During the admission of a male client to the mental health unit, the client tells the nurse that he had a panic attack today and ran out of the physician's office. Which question is most important for the nurse to ask this client? A. On a scale of 1 to 10 how do you rate your anxiety level? B. How would you describe your mood right now? C. Have you had any thoughts of hurting yourself? D. What medications have you taken in the last 24 hours? Assessing for suicidal ideation is most essential. The other assessments should be made, and to ensure client safety, thoughts of self-harm are most important. An adolescent who attempted suicide with a drug overdose arrives in the emergency department with an empty 30-tablet bottle of acetaminophen (Tylenol). Which action should the nurse implement? A. Administer acetylcysteine (Mucocyst). B. Monitor cardiac rhythm for flat T waves. C. Check both serum AST and ALT levels. D. Prepare to administer Syrup of Ipecac. Tylenol overdose is treated with immediate administration of Mucomyst to prevent hepatic insult. The other actions are not indicated. A female client who is admitted for treatment of uncontrolled diabetes mellitus is withdrawn and tearful. She complains she has gained excessive weight because she hates her diet, hates taking insulin, and just wants to be normal again. What therapeutic action should the nurse take? A. Assist the client in verbalizing distress about the disease. B. Inquire about emotional factors affecting the client's present condition. C. Assess priorities to be set for the client's overall nursing care plan. D. Encourage the client to emotionally accept the chronicity of the disease. [Show More]

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