NURSING 4739 Hesi Mental Health Version 2 2020

NURSING 4739 Hesi Mental Health Version 2 2020 1. An older male resident of a long-term care facility who is chronically depressed has become more reclusive and refuses to leave his room today. His family moved away fr ...

NURSING 4739 Hesi Mental Health Version 2 2020 1. An older male resident of a long-term care facility who is chronically depressed has become more reclusive and refuses to leave his room today. His family moved away from the local area, and they are unable to visit as much as they did in the past. Which comment by the nurse is likely to be most helpful to this client?  May I sit with you for a while? 2. A male client with long history of alcohol dependency arrives in the emergency department describing the feelings of bugs crawling on his body. His blood pressure is 170/102, his pulse rate is 110 bpm, and is blood alcohol level is 0mg/dL. Which prescription should the RN administer?  Lorazepam (Ativan). 3. The RN is completing the admission assessment of an underweight adolescent who is admitted to a psychiatric unit with a diagnosis of depression. Which finding requires notification to the HCP?  Potassium level of 2.9 mEq/dl. 4. A woman is brought to the psychiatric clinic by her husband. He reports that his wife is reluctant to leave home because of what she describes as a fear of open places and crowds. Which nursing problem applies to this client’s behavior?  Anxiety related to real or perceived threat to physical integrity. 5. A client is receiving benztropine mesylate (Cogentin) for drug-induced extrapyramidal syndrome (EPS). Which finding indicates that the RN should further evaluate the client?  Presence of a dry mouth. 6. A male client in the mental health unit is guarded and vaguely answers the nurse’s questions. He isolates in his room and sometimes opens the door to peek into the hall. Which problem can the RN anticipate?  Delusions of persecution. 7. A female client with obsessive compulsive personality disorder is admitted to the hospital for a cardiac catheterization. The afternoon before the procedure, the client begins to keep detailed notes of the nursing care she is receiving, and reports her findings to the RN at bedtime. What action should the nurse implement?  Encourage the client to express her feelings regarding the upcoming procedure. 8. During admission to the psychiatric unit, a female client is extremely anxious and states that she is worried about the sun coming up the next day. What intervention is most important for the RN to implement during the admission process?  Assist the client in developing alternative coping skills. 9. A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The RN also determines that the client is homeless and is exhibiting suspiciousness. The client’s plan of care should include what priority problem?  Acute confusion. 10. The occupational health nurse is working with a female employee who was just notified that her child was involved in a MVA and taken to the hospital. The employee states, “I can’t believe this. What should I do?” Which response is best for the RN to provide in this crisis?  Call for transportation to the hospital. 11. An adolescent male client is hospitalized after he threatened a teacher at school. He admits feeling angry because his mother tricked him and brought him to the hospital. The client states that when his mother visits, he plans to get his belongings from her, but is not going to talk to her. Which activity is most important for the nurse to complete before the mother arrives?  Methods of clear communication 12. The nurse is developing unit policies that will include nursing guidelines for maintaining a therapeutic milieu. Which interventions should be included when providing a therapeutic milieu in an inpatient setting?  Regularly scheduled unit activities for peer interaction. 13. The RN on the evening shift receives report that a client is scheduled for electroconvulsive treatment (ECT) in the morning. Which intervention should the Rn implement the evening before the scheduled ECT?  Keep the client NPO after mid-night. 14. An adult comes to the mental health clinic and walks back and forth in front of the office door, but does not enter the office. He then walks around a chair that is in the hallway several times before sitting down in the chair. What action should the nurse take first?  Observe the client in the chair. 15. A young adult male who was recently diagnosed with bipolar disorder takes lithium carbonate daily. He is graduating from high school next month, and he tells the school nurse that wants to live away from home for college. What information is most important for the nurse to provide the client and his family?  Lithium level routinely. 16. The RN is teaching a client about the initiation of the prescribed abstinence therapy using disulfiram (Antabuse). What information should the client acknowledge understanding?  Remain alcohol free for 12 hours prior to the first dose. 17. A male client with schizophrenia is admitted to the mental health unit after abruptly stopping his prescription for ziprasidone (Geodon) one month ago. Which question is most important for the RN to ask the client?  Do you hear sounds or voices that others do not hear? 18. A client who has agoraphobia (a fear of crowds) is beginning desensitization with the therapist, and the RN is reinforcing the process. Which intervention has the highest priority for this client’s plan of care?  Establish trust by providing a calm, safe environment. 19. Intimate Partner Violence – wife of an abusive husband has difficulty time leaving due to which select all that apply  Children  religious and marriage  financial dependency 20. A client on the mental health unit is becoming more agitated, shouting at the staff, and pacing in the hallway. When the PRN medication is offered, the client refuses the medication and defiantly sits on the floor in the middle of the unit hallway. What nursing intervention should the RN implement first?  Take other clients in the area to the client lounge. 21. A client is admitted to the mental health unit and reports taking extra antianxiety medication because, “I’m so stressed out. I just want to go to sleep.” The RN should plan one-on-one observation of the client based on which statement?  “I don’t want to walk. Nothing matters anymore.” 22. A male hospital employee is pushed out the way by a female employee because of an oncoming gurney. The pushed employee becomes very angry and swings at the female employee. Both employees are referred for counseling with the staff psychiatric RN. Which factor in the pushed employee’s history is most related to the reaction that occurred?  Was physically abused by his mother. 23. A high school girl reveals to the high school RN that she has been engaging in self-induced vomiting as weight-control measure. Which initial assessment should the RN focus on with this adolescent?  -frequency of binging and purging behaviors 24. Pt is getting oriented to the unit and replies “there are no TVs in the room” What is the nurse’s best respond?  -it is important to be out of your room and talking to others 25. The nurse orients a female client with depression to the new room on the mental health unit. The client states “It seems strange that I don’t have a T.V in my room.” Which statement would be best for the RN to provide?  “You can watch T.V as much as you want outside of your room.” 26. Depression patient suddenly becomes happy and excited emotion  Continuously watch patient 27. An adolescent make receives a prescription for an antidepressant drug because he is exhibiting a depressed affect. While the client is taking the antidepressant, which comparison of the client’s behavior before and after taking the drug is most important for the nurse to obtain?  An emotional quality of his attitude. 28. The RN is admitting a male client who take lithium carbonate (Eskalith) twice a day. Which information should the RN report to the HCP immediately?  Nausea and vomiting. 29. Alcohol-Pancreatitis health assessment of history of alcohol dependency  Pancreatitis 30. A male client is admitted to the psychiatric inpatient unit with a bandaged flesh wound after attempting to shoot himself. he is recently divorced one year ago, lost his job four months ago, and suffered a break up of his current relationship last week. What is the most likely source of this client's current feelings of depression?  a sense of loss 31. What is the most important goal for a client diagnosed with major depression who has been receiving an antidepressant medication for two weeks  No attempt to commit suicide 32. A female high school teacher who was a child of alcoholic parents seeks counseling at the community health clinic because of depression over a student who was killed by a drunk driver. After several weeks of counseling, which behavior is the best indicator that the client is coping well with the anxiety related to the student's death  becomes the faculty sponsor for students against drunk driving (SADD) 33. one on one session and nurse begins to get angry at patient  terminate session 34. A woman who started chemotherapy three days ago for cancer of the breast calls the clinic reporting that she is so upset she cannot sleep. The client has several PRN medications available. Which drug should the nurse instruct her to take?  Lorazepam (Ativan) 8 mg PO HS 35. Antabuse (Disulfiram) they must avoid?  Over the counter medication that contains alcohol. 36. When a male client is asked about his reason for coming to the mental health clinic he replies, "It all started because I work in a hostile work environment. My boss would not let me go to a religious service, so I went to human resources, and they didn't want to do anything. It has been a really difficult time for me." Which response should the nurse provide?  "Have the feelings associated with these events brought you to the clinic?" 37. ECT therapy non responsive  have you taken erectile dysfunction meds? 38. The RN on the day shift receive report about a client with depression who was in bed most of the weekend. The RN walks into the client’s room in the morning and finds the client in bed. What intervention is best for the RN to implement?  Assist the client out of bed and involve in activity. 39. A client becomes agitated when the nurse is talking to his wife. He has not eaten in 3 days. What should the nurse do?  Take to quiet room and give PB crackers. 40. Female client who is 5 feet 3 inches and weighs 90 lbs. What is the most immediate concern?  Intermittent palpitations 41. While interviewing a client, the nurse takes notes to assist with accurate documentation later. Which statement is most accurate regarding note-taking during an interview?  The nurse’ ability to directly observe the client’s nonverbal communication is limited with note taking. 42. A middle-aged female client with no previous psychiatric history is seen in the mental health clinic because her family describes her as having paranoid thoughts. On assessment, she tells the nurse “I want to find out why these people are stalking me” which response should the nurse provide?  “It sounds like this experience is frightening for you” 43. After receiving treatment for anorexia, a student asks the school nurse for permission to work in the school cafeteria as part of the school’s work study program. What action should the nurse take?  Recommend assignment to the receptionist’s office. 44. A teenager who has lost 20 pounds in the last three months is admitted to the hospital with hypotension and tachycardia. The client reports irregular menses and hair loss. Which intervention is most important for the nurse to include in the clients plans of care?  A. Initiate caloric and nutritional therapy. 45. A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit’s day room. What action should the nurse implement first?  Listen to what the client is saying. 46. A female client, who is wearing dirty clothes and has afoul body odor, comes to the clinic reporting feeling scared because she is being stalked. What action is most important for the nurse to take?  Offer the client a safe place to relax before interviewing her. 47. Patient on clozapine.  WBC 48. A female client engages in repeated checks of door and window locks, behavior that presents her from arriving on time and interferes with her ability to function effectively. What action should the nurse take?  Plan a list of activities to be carried out daily. 49. How do you take Antabuse?  Each morning beginning 48 hours after your last drink of alcohol 50. A client who is admitted with a closed head injury after a gall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the nurse identify as the priority?  Place in a side-lying position with head of bed elevated 51. The nurse is using the CAGE questionnaires as a screening tool for a client who is seeking help because his wife said he had a drinking problem. What information should the nurse explore indepth with the client based on this screening tool?  Efforts to cut down, annoyance with questions, guilt, drinking as an “Eye-opener”. 52. Client is admitted to the mental health unit and sitting in corner of day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. What action should the nurse implement?  Attempt to ask the client simple questions. 53. On admission to the mental health unit, a client diagnosed with schizophrenia tells the nurse that he is the son of God. Based on this statement, which intervention should the nurse include in this client’s plan of care?  Confront his delusion as not consistent with reality. 54. When developing a plan of care for a client admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing problem has the highest priority?  Ineffective breathing patterns. 55. Which client information indicates the need for the nurse to use the CAGE questionnaire during the admission interview?  Describes self as a social drinker who drinks alcoholic beverages daily. 56. A female client on a psychiatric unit is sweating profusely while she vigorously does pushups and then runs the length of the corridor several times before crashing in to the furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbances, the client shouts," I am the boss here. I do what I want." Which nursing problem best supports these observations  Risk for other related violence related to disruptive behavior. 57. A client who is known to abuse drugs is admitted to the psychiatric unit. Which medication should the nurse anticipate administering to a client who is exhibiting benzodiazepine withdrawal symptoms?  Chlordiazepoxide (Librium). 58. Patient says “I'm going to shoot myself”  Stop the client from leaving the unit 59. A client who is homeless is diagnosed with schizophrenia and admitted on an involuntary basis to a mental health hospital 4 days ago. The client stopped taking prescribed antipsychotic drugs approximately one month ago. Since hospitalization the client continues to have poor judgment and refuses all medications. What action should the RN take?  Provide the client with medication if the client presents an imminent risk to self and others. 60. A client with schizophrenia explains that she has 20 children and then very seriously points to the RN and explains that she is one of them. What is the most therapeutic response for the RN to provide?  “My name tag shows that I am a RN here.” 61. A male client who recently lost a loved one arrives at the mental health center and tells the RN he is no longer interested is his usual activities and has not slept for several days. Which priority nursing problem should the RN include in the client’s plan of care?  Sleep deprivation. 62. A client on the mental health unit is becoming more agitated, shouting at the staff, and pacing in the hallway. When the PRN medication is offered, the client refuses the medication and defiantly sits on the floor in the middle of the unit hallway. What nursing intervention should the RN implement first?  Take other clients in the area to the client lounge. 63. A female client requests that her husband be allowed to stay in the room during the admission assessment. When interviewing the client, the RN notes a discrepancy between the client’s verbal and nonverbal communication. What action does the RN take?  Pay close attention and document the nonverbal messages. 64. A client with depression remains in bed most of the day, and declines activities. Which nursing problem has the greatest priority for this client?  Refusal to address nutritional needs.