MERGERED HESI RN MENTAL HEALTH NEW FILE 2022/2023 ACTUAL EXAM LATEST UPDATE

MERGERED HESI RN MENTAL HEALTH NEW FILE 2022/2023 ACTUAL EXAM LATEST UPDATE HESI RN MENTAL HEALTH V1 1. A client is Prescribed Risperidone (Risperdal) forschizophrenia. Which Side Effects Should the nurse report to the Health Provider? Fever, Tachycardia, Diopheris (sweathing) 2. A homeless women who is well-educated and has chronic schizophrenia is admitted to the mental health unit when found by the police walking in the middle of the street. The client presents with strong body odor, dirty clothes and avoliation. After a week of neurolepticdrug therapy drug therapy, the client discusses with the nurse her thoughts about bathing. Which statement suggest that the client is progressing? I feel good when I take care of myself. 3. A young adult with eroded tooth enamel presents to the clinic with multiple complaints including severe pain in the chest and upper abdomen that occurred when the client induced vomiting after eating a large breakfast. The client also reports severe hearthburn in the last week and describes a history of taking laxatives and eating prunes whenever overeating. What client problem should address first? Erosion of tooth enamel 4. A young adult male receives a prescription for disulfiram to help maintain abstinence from alcohol. What information should the nurse include in a teaching plan for this client? Check labels of OTC drug for alcohol content 5. A older male resident of a long-term care facility who is chronically depressed. Has become more reclusive and refusesto leave hisroom today. Hisfamily moved away from a 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 6. The nurse develops a plan of care for a female client who scratches her wrist in attempt to deal with anxiety. Which client outcome is most important to include in the plan of care. Demonstrates effective ways to cope with anxiety. 7. Aclientwhorecentlyexperiencedthedeathofasignificantotherarivesathemental healthcenter.Theclientreportslosofinterestinusualactivities,expresesawishtobe withthedecreasedsignificantother,hasbeneatingverylitle,andhasnotsleptin severaldays.WhichclientstatementismostimportantfortheRNtoexploreathistime? Not sleeping for several days. 8. An adolescent male client is hospitalized after he threatened a teacher in school. He admits feeling angry because his mother tricked him and brought him tp the hospital . The client steates that when his mother visits, he plans to her his belonging from her, but is not going to talk to her. Which activity is most important for the nurse to complete before the mother arrives? Discuss methods for clearly communicating 9. The charge nurse of the psychiatric unit observes clientsin the day area. Which client is exhibiting symptoms of a conversion disorder? A young women who suddenly goes blind with no indication of organic pathology 10. A client diagnosed with schizophrenia looks frightened and tells the nurse. “ I keep hearing the voicestelling me to hurt somebody. Don’t you hear them? Which response is the best for the nurse to provide? I don’t hear the voices, but you seem very frightened 11. During admissions assessment to the mental health unit, a client reportsthat the people at the office, where the client works, are antagonistic and the client is thinking of the shooting the supervisor. The client asks the nurse not to revel this to anyone else. The nurse immediately notifies the clients therapist and other team members of the client’s thoughts. The therapist then calls the client’s supervisors and shares the client’s thoughts about shooting the supervisors. what outcome is appropriate based on the action of the nurses? The nurse is reprimanded for divulging confidential patient information without obtaining informed consent 12. When implementing a therapeutic on a psychiatric unit, which intervention is most important for the nurse to implement. Encourage client participation in planning weekly activities 13. TheRNurseontheeveningshiftreceivesreporthataclientischeduledfor electroconvulsivetreatment(ECT)inthemorning.WhichinterventionshouldtheRn implementheeveningbeforethescheduledECT? Keep The client NPO after midnight 14. Amaleadultcomestothementalhealthclinicandwalksbackandforthinfrontofthe officedoor,butdoesnotentertheoffice.Hethenwalksaroundachairthatisinthe halwayseveraltimesbeforesitingdowninthechair.Whatactionshouldthenursetake first Observe the client in the Chair 15. Afemaleclientisbroughtotheemergencydepartmentafterpoliceofficersfoundher disoriented,disorganized,andconfused.TheRNalsodeterminesthatheclientis homelesandisexhibitingsuspiciousnes.Theclient’splanofcareshouldincludewhat priorityproblem? Acute confusion 16. Whenassessinga7-year-oldgirl,thenursenotesthatshehasmultiplebruises onherbackanduperarms.Thechild'sauntelsthenursethathechild's parentsabusedrugsandalcohol.Whatinterventionismostessentialforthe nursetoimplement?Assement findings should be reported to the proper legal authorities 17. AmaleclientwithalonghistoryofalcoholdependencyarrivesintheEmergency Departmentdescribingthefelingofbugscrawlingonhisbody.Hisblod pressureis170/102,pulserateis10beats/minute,andblodalcoholevel (BAL)is0mg/(dL).Whichprescriptionshouldthenurseadminister? Lorazepam (Ativan) 18. Aclientonthementalhealthunitisbecomingmoreagitated,shoutingathestali, andpacinginthehalway.WhenaPRNmedicationisofered,theclientrefuses themedicationanddefiantlysitsontheflorinthemidleoftheunithalway. Whatnursinginterventionshouldthenurseimplementfirst? Take other client in the area to the client lounge 19. Amiddle-agedremaleclientwithnopreviouspsychiatrichistoryiseninthemental healthclinicbecauseherfamilydescribesherashavingparanoidthoughts.On asesment,shetelsthenurse“Iwantofindoutwhythesepeoplearestalkingme” whichresponseshouldthenurseprovide? It sounds like this experience id frightening you. 20. FolowinginvolvementinaMVC,amiddleagedadultclientisadmitedtothehospital withmultiplefacialfractures.Theclient’sbloodalcoholevelishighonadmision. WhichPRNprescriptionshouldbeadministerediftheclientbeginstoexhibitsignsand symptomsofdeliriumtremens(DTs)? Lorazepam (Ativan) 2mg IM. 21. A client with borderline personality disorder tells the nurse, "You are the best nurse on the unit! The other nurses don't care about me the way you do." Which response is best for the nurse to provide this client? I am not the best nurse. All the nurses are good. 22. 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 wantsto live away from home for college. What info is most important for the nurse to provide the client and his family? His serum lithium levels should be routinely evaluated. 23. .AmaleclientelstheRNthathedoesnotwantotaketheatypicalantipsychoticdrug, olanzapine(Zypexa),becauseofthesideefectsheexperiencedwhenhetookthedrugfor ayear.Whichexperienceismostlikelyrelatedtotakingolanzapine? Weight gain of 75 pounds 24. A client is discussing feeling related to recent loss with the nurse. The nurse remains silent when the client says, “ I don’t know how I will gone” wha isthe most likely reason for the nurse’s behavior? Silence allows the client to reflect on what is said 25. A successful businessman presents to the community mental health center caining of sleeplessness and axiety over hisfinancialstatus. What action should the nurse take to assist this client in diminishing his anxiety? Teach him to limit sugar and caffeine intake. 26. The nurse notesthat a client with a history of self-mutilation hasincreased body tension and is pacing in the hallway. Which nursing intervention is most important at thistime Complete a thorough room search to ensure client does not have access to objects that can be used self-harm. 27. The nurse is planning client teaching for a 35-year-old client with early alcoholic cirrhosis. Which self-care measuresshould the nurse emphasize for the client’srecovery Vitamin b and multivitamin 28. TheRNisadmitingamaleclientwhotakelithiumcarbonate(Eskalith)twiceaday. WhichinformationshouldtheRNreportotheHCPimmediately Nausea and vomiting 29. During a high school class on substance abuse, a student tells the group. “ If I tried cocaine, I know I could handle it. I know when to stop.” What response is best for the nurse to provide. Denial of addiction problem is often the response to the behavior. 30. What is the most important goal or a client with major depression who has been receiving an antidepressant medication for two weeks?. Does not attempt to commit suicide. 31. A male client turns over a table in the dayroom of a psychiatric unit and threatens to throw a chair at another client. Which actions is the most important for the nurse to implement. Obtain staff assistance to help diffuse the escalating situation. 32. The nurse is using the cage questionnaire as a screening tool for a client sseeking whelp because his life said he had a drinking problem. What information should the nurse explore indepth with the client based on this screening tool. Effort to cut down, annoyance with questions, guilt, drinking as an “eye opener.” 33. The nurse interacts with a male client who is very depressed and slow to respond to questions. The nurse asks the client to explain how he is feeling, but the client looks down at the table. What action would be best for the nurse to implement? Return at a later time to talk. 34. A male with alcohol dependene is admitted to the hospital with abdominal pain. What it intervention should the nurse implement? Providence a calm, quiet, well-lit environment . 35. An adult female is brought to the emergency center after fainting at work. The nurse completes an assessment of the client and identifies caregiver role strain as a nursing problem. What info best supports this problem. Cares for an older parent and her child 36. AclientwithBulimiaanddepresionwhoistakingphenelzine(Nardil)90mgdailyis admitedtoanacutecarehospitalforuncontroledhypertension.Whatdietarychoices shouldtheRNinstructheclientoavoid? Pepperoni pizza 37. After meeting with health provider, a client who is diagnosed with bipolar disorder screaming and stomping both feeile pacing the hallway What action should the nurse take? accompany the client to a quiet area of the unit 38. A client is admitted to the mental health unit and sit un the corner of the 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 question 39. A recently widowed middle-aged female client presents to the psychiatric for evaluation and tells the nurse that she has “little to live” she describes one previous suicidal and to help ensure client safety, which action is best for the nurse to implement? Encourage the client to remove the gun from her possess 40. Amaleclientwithknownauditoryhalucinationsbeginstalkingloudlyandgesturing wildlywhileintheunit’sdayroom.Whatactionshouldthenurseimplementfirst? Listen to what the client is saying 41. Aclientwhoisadmitedwithaclosedheadinjuryafteragalhasabloodalcoholevel (BAL)of0.28(28%)andisdifficultoarouse.Whichinterventionduringthefirst6hours folowingadmisionshouldthenurseidentifyasthepriority? Place in a side-lying position with head of bed elevated. 42. A male Native-American client diagnosed with depression is 20 min late for an appointment with the psychiatric nurse is an outpatient clinic. Which action should the nurse take. Use remainder of the time to continue the clients counseling. 43. The nurse is taking history of any young adult who is 5 feet 3 inches tall weights 90 pounds. Which reported finding is most important for the nurse to addressimmediately Absence of menstrual cycle 44. Afemaleclientonapsychiatricunitisweatingprofuselywhileshevigorouslydoes push-upsandthenrunsthelengthofthecoridorseveraltimesbeforecrashinginto furnitureinthesitingroom.Pickingherselfup,shebeginstotoschairsaside,looking foraredonetositin.Whenanotherclientobjectstothedisturbance,theclientshouts,“I amtheboshere.IdowhatIwant.”Whichnursingproblembestsupportsthese observations? Risk for other related violence related to disruptive behavior. 45. On admission to the mental health unit, a client with schizophrenia tellsthe nurse that he is the son of God. Based on this statement ehich intervention should the nurse include in this client’s plan of care. Ensure the clients environment is safe. 46. Which client statement suggest to the nurse that is using a defense mechanism of projection to deal with anxiety relates to admission to a psychiatric unit? I am here because the police thought I was doing something V2 47. Whilecaringforanolderclient,theRNobservesmultiplebruisesOvertheclient’slegs, arms,back,andglutealareas.Whentheclient.Contact,theRNsuspectselderabuse. WhatactionshouldtheRNtake? Measureanddocumentsize,shapeandcolorbruisedarea 48. TheRNisperformingintakeinterviewsatapsychiatricclinic.Afemaleclientwitha knownhistoryofdrugabusereportsthatshehadaheartatackfouryearsago.Useof whichsubstanceplacestheclientathighestriskformyocardialinfarction? Methamphetamine 49. Aclientwhoishomelesisdiagnosedwithschizophreniaandadmitedonaninvoluntary basistoamentalhealthhospital4daysago.Theclientstoppedtakingprescribed antipsychoticdrugsapproximatelyonemonthago.Sincehospitalizationtheclient continuestohavepoorjudgmentandrefusesalmedications.WhatactionshouldtheRN take? Administeralongactingantipsychoticmedicationsothatheclientcanbedischargedtoa shelter. 50. Aftereceivingtreatmentforanorexia,astudentaskstheschoolnurseforpermisionto workintheschoolcafeteriaspartoftheschool’sworkstudyprogram.Whatactionshould thenursetake? Recommendasignmentothereceptionist’soffice. 51. Amaleclientcomestotheemergencycenterhehasanerectionthatwilnoresolvethe clientreportsthatheistakingtrazodone(desyrel)forinsomniawhichinformationismost importantforthenursetoaskthisclient? Haveyoutakenanymedication forerectiledysfunction?” 52. Onadmisiontothementalhealthunit,aclientdiagnosedwithschizophreniatelsthe RNthatheisthesonofgod.Basedonthistatement,whichinterventionshouldtheRN includeinthisclient’splanofcare? Confrontshisdelusionasnotconsistent withreality 53. Thenurseonthedayshiftreceivesreportaboutaclientwithdepresionwhowthe wekend.Thenursewalksintotheclient’sroominthemorningandfindsthewhat interventionisbestforthenursetoimplement? Asisthecliento getoutbedandinvolvedinanactivity 54. WhichclientinformationindicatesthenedfortheRNtouseCAGEquestionnaireduring theadmisioninterview? Describe self associal drinker who drinks alcoholic beverages daily 55. AfemaleclientadmitedtothementalhealthunitstartstoshoutandscreamatheRN. WhatisthebestapproachfortheRNtotake? Stay quietly with the patient. 56. Awomanisbroughtothepsychiatricclinicbyherhusband.Hereportsthathiswifeis reluctantoleavehomebecauseofwhatshedescribesasafearofopenplacesand crowds.Whichnursingproblemappliestothisclient’sbehavior? Anxiety related to real or perceived threat to physical integrity 57. Aclientisreceivingbenztropinemesylate(Cogentin)fordrug-inducedextrapyramidal syndrome(EPS).WhichfindingindicatesthatheRNshouldfurtherevaluatetheclient? Presence of a dry mouth 58. Amaleclientinthementalhealthunitisguardedandvaguelyanswersthenurse’s questions.Heisolatesinhisroomandsometimesopensthedoortopekintothehal. WhichproblemcantheRNanticipate? Delusion of persecution 59. Afemaleclientengagesinrepeatedchecksofdoorandawindowlockbehaviorthat preventsherfromarivingontimeandinterfereswithherabilitytofunctionefectively. Whatactionshouldthenursetake? Plan a list of activities to be carried out daily 60. A female client with obsessive-compulsive disorder is admitted to the hospital for a cardiac catherization. The afternoon before the procedures, the client begins to kepp detailed notes of the nursing care she is receiving, and reports her finding to the nurse at bedtime. What action should the nurse implement. Encourage the client to express her feelings regarding the upcoming procedure 61. 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. Administer a PRN sedative to help relieve anxiety. 62. Afemaleclientisbroughtotheemergencydepartmentafterpoliceofficersfoundher disoriented,disorganized,andconfuse.Thenursealsodeterminesthatheclientis homelesandslightlysuspicious.Thisclient’streatmentplanshouldincludewhatpriority problem? Acute confuse 63. The occupational health nurse is working with a female employee who just notified that her child was involved in a motor vehicle collision and taken to the hospital. The employee states,” I can’t believe this. What should I do? Which response isthe best fo r the nurse to provide in this crisis? Call a transportation to the hospital 64. AclientelstheRNthathehasanIQof400+andisageniusandaninventor.Healso reportsthatheismariedtoafemalemoviestarandthinksthathisbrotherwantsasexual relationshipwithher.Whatistheprioritynursingproblemforadmisiontothe psychiatricunit? Ineffective sexual patterns 65. TheRNisprovidingcareforaclientdiagnosedwithborderlinepersonalitydisorderwho haself-inflictedlacerationsontheabdomen.WhichapproachshouldtheRNusewhen changingthisclient’sdresing? Perform the dressing change in a non-judgmental manner 66. Whilesitinginthedayroomofthementalhealthunit,amaleadolescentavoidseye contact,looksathefloor,andtalksoftlywheninteractingverbalywiththeRN.The twotradeplaces,andtheRNdemonstratestheclient’sbehaviors.Whatisthemaingoal ofthistherapeutictechnique? Alowtheclientoidentifythewayheinteracts. 67. Anantidepresantmedicationisprescribedforaclientwhoreportslepingonly4hours inthepast2daysandweightlosof9lbswithinthelastmonth.Whichclientgoalismost importantoachievewithinthefirsthredaysoftreatment? Sleep at least six hours a night. 68. Whenpreparingtoadministertodomesticviolencescreningtooltoafemaleclient, whichstatementshouldtheRNprovide? All Clients are screened for domestic abuse because it is common in our society. 69. Ayoungadultfemalevisitsthementalhealthcliniccomplainingofdiarhea,headache, andmuscleaches.Sheisafebrile,denieschils,andalaboratoryfindingsarewithin normalimits.DuringthephysicalasesmentheclientelstheRNthathersisterthinks sheisneuroticandcalsherahypochondriac.WhichresponseisbestfortheRNto provide?Besideyoursistercomments,whatinyourlifeistroublingyou. 70. Thenurseisleadinggroupontheinpatientpsychiatricunit.Whichapproachshouldthe nurseuseduringtheworkingphaseinthegroupdevelopment?Helpingclientsidentify areasofproblemintheirlives. 71. Amaleclientwithschizophreniaisdemonstratingecholalia,whichisbecomingannoying tootherclientsontheunit.WhatinterventionisbestfortheRNtoimplement.Escort theclientohisroom. 72. Aclientisadmitedforbipolardisorderandalcoholwithdrawal,depresivephase.Based onwhichasesmentfindingwiltheRNwithholdtheclonidine(Catapres)prescription? A.Bloodpresurereadingsof90/62mmHgto92/58mmHg. 73. TheRNontheeveningshiftreceivesreporthataclientischeduledfor electroconvulsivetreatment(ECT)inthemorning.WhichinterventionshouldtheRn implementheeveningbeforethescheduledECT? Keep the client NPO after midnight 74. AclientwithBulimiaanddepresionwhoistakingphenelzine(Nardil)90mgdailyis admitedtoanacutecarehospitalforuncontroledhypertension.Whatdietarychoices shouldtheRNinstructheclientoavoid? Pepperoni pizza 75. Amentalhealthworkeriscaringforaclientwithescalatingagresivebehavior.Which actionbythementalhealthworkerwarantsimmediateinterventionbytheRN?Is attemptingthephysicalrestraintheclient. 76. Aclientwhorecentlyexperiencedthedeathofasignificantotherarivesathemental healthcenter.Theclientreportslosofinterestinusualactivities,expresesawishtobe withthedecreasedsignificantother,hasbeneatingverylitle,andhasnotsleptin severaldays.WhichclientstatementismostimportantfortheRNtoexploreathistime? Notslepingforseveraldays. 77. .Whendevelopingaplanofcareforaclientadmitedtothepsychiatricunitfolowing aspirationofacausticmaterialrelatedtoasuicideatempt,whichnursingproblemhas thehighestpriority? Ineffective breathing pattern 78. .Whendevelopingaplanofcareforaclientadmitedtothepsychiatricunitfolowing aspirationofacausticmaterialrelatedtoasuicideatempt,whichnursingproblemhas thehighestpriority? Riskforotherrelatedviolencerelatedtodisruptivebehavior 79. ARNispreparingthephysicalenvironmentointerviewanewclientforadmisiontothe mentalhealthunit.Whichenvironmentalsetingfacilitatesthebestoutcomeofthe interview? Reducethenoiselevelintheroombyturningoffthetelevisionandradio. 80. Themotherofan8montholdinfantwithprofoundmentalandphysicaldisabilitiestels thenursehowdepresedsheisbecausesheisbecausesherealizesthatherchilfwilnever achievenormalgrowthanddevelopmentmilestones.Howshouldthenurserespondtothis mother? Askthemotherifshehaseverthoughtaboutharmingherselforchild. 81. Aclientwithschizophreniaisadmitedtothepsychiatriccareunitforagresive behavior,auditoryhalucinations,andpotentialforsafeharm.Theclienthasnotben takingmedicationsasprescribedandinsiststhathefoodhasbenpoisonedandrefuses toeat.WhatinterventionshouldtheRNimplement? Providetheclientwithfoodinunopencontainers. 82. Anurseisprovidingeducationaboutstrategiesforasafetyplanforafemaleclientwhois avictimofintimatepartnerviolence.Whichstrategieshouldbeincludedinthesafety plan?A.Purchaseaguntouseforprotection Establishacodewithfamilyandfriendstosignifyviolence. Plananescaperoutetouseiftheabuserblocksthemainexit. Haveabigreadythathasextraclothesforselfandchildren 83. TheRNisadmitingamaleclientwhotakelithiumcarbonate(Eskalith)twiceaday. WhichinformationshouldtheRNreportotheHCPimmediately? Nausea and vomiting 84. Amaleclientwhoisadmitedwithdeliriumtremensisdehydratedandexperiencing auditoryhalucinations.Hehasabruised,swolentongueandisconfused.Indevelopinga planofcare,whichactionshouldtheRNincludetoensuretheclientisphysiologicaly stable? Monitor Vital Signs. 85. Thenurseisteachingaclientaboutheinitiationofaprescribedabstinencetherapyusing disulfiram(Antabuse).Whatinformationshouldtheclientacknowledgeunderstanding? Remain alcohol free for 12 hours prior the first dose. 86. TheRNisworkingwithamaleclientatacommunitymentalhealthcenterwhenthe clientreportshearingvoicesthatelhimtogetaknifefromthekitchenandhurthimself. WhatinterventionismostimportantfortheRNtoimplement? Assign a UAP to remain with the client all the times 87. Ahomelesclientwhoreportsfelingsadanddepresedtelsthementalhealthnursethat inthepast2dayshehasonlyhad4hoursofslep.Whichactionismostimportantfor theRNtoimplementwithinthefirst24hoursaftertreatmentisinitiated? Allow the client to rest and sleep. 88. WhichclientstatementsugeststheRNthatheclientisusingadefensemechanismof projectiontodealwithanxietyrelatedtoadmisiontoapsychiatricunit I am here because the police though I was doing something wrong 89. Amaleclientisadmitedtothepsychiatricinpatientunitwithabandagedfleshwound afteratemptingtoshoothimself.Hewasdivorcedoneyearago.Losthisjobfourmonths ago,andsuferedabreakupofiscurentrelationshiplastwek.Whatismostlikely sourceofthisclient’scurentfelingsofdepresion? A sense of loss 90. Thenursedocumentsthementalstatusofafemaleclientwhohasbenhospitalizedfor severaldaysbycourtorder.Theclientstate,“Idon’tnedtobehere”andtelsthenurse thatshebelievesthathetelevisiontalkstoher.Thenurseshoulddocumenthese asesmentfindingsinwhichsectionofthementalstatusexam? Insight and judgment 91. Anolderaleclientwithschizophreniaisfoundsmearingfecesnthebathroomwalsof thechronicmentalhealthunitwhereheresides.WhatactionshouldtheRNimplement? Escort the client out of the bathroom 92. Thenursecompleteanasesmentofaclientwhoisexperiencingintimatepartner violence(IPV)whichfindingoftheinjurieshouldthenurseincludeinthe documentation? Photographs HESI RN MENTAL HEALTH Middle age female with no previous mental illness and the family states that she is having paranoid thoughts, pt states: "I want to find out why people are stalking me". Therapeutic response: "it sounds like this experience is frightening for you" Pt is mad at mom for turning him in and wants mom to bring belongings and does not want to talk to her. What action does the nurse need to take before the visit? Discuss methods of clear communication Duty to warn question: Pt tells the nurse that he wants to kill his boss, nurse tells healthcare provider, healthcare provider tells his boss. What disciplinary action is needed? None. The action was appropriate Defense mechanism question: for projection "I am here because the police said I did something wrong" pt with stress admits to taking care of the ex-husband 's parents. Which defense mechanism is this? Regression therapeutic Milieu: Pt had a recent suicide attempt after his wife offered divorce, lost his job, and his best friend moved away. What is the best nursing intervention to support therapeutic Milieu ? Encourage activities that will allow him to take control over his environment Interview noting taking question arrange the setting and decrease any stimuli Prep from D/C from the psychic unit, what should the nurse include ? Explore that pt's feelings regarding the discharge People in a group home and they are wiping feces on the wall. What is the nurse's highest priority? Infection control Pt refuses to take medications and in defiance sits in the middle of the hallway floor. Best nursing action? To move other clients to another room Nurse and client trade roles: nurse demonstrates bad behavior of the client. Why is this important? Role play assists the client to recognize their own behavior Pt states, "I don't know, I just can't think". What is the best activity by the nurse? Set daily goals Adolescent interrupts group to talk about pets during group therapy. Best nursing action? Redirect him with a handout Crisis intervention: male client feeling stressed, increased anger over the last month. What is an appropriate nursing action? Ask to identify problems that have occurred during the last month Pt discharged after diening suicide thoughts to the healthcare provider. Pt mutters as walking towards the door, " Now I can kill myself". What is the best nursing action? Notify the HCP and stop the patient from leaving Long term care client who is anxious and agitated. What is the best nursing action? decrease stimuli by lowering the TV volume Elderly pt anxious about procedure. What is the best nursing action? Encourage the pt to express their feelings about the procedure Agoraphobia question: Highest priority question: To establish trust by providing a calm, safe environment Agoraphobia question: client afraid to leave house due to fear of open places. What is the nursing diagnosis? Anxiety related to real or perceived fear OCD: a client that continues to wash hands for 2 hours. What is the priority nursing intervention? To set limits OCD: a client that keeps cleaning windows. What should you do? Give a list of activities A pt with PTSD after rape who displays a detached effect. Best action from nurse? To ask if they are thinking about harming themselves PTSD: what should you include in the plan of care? to provide a quiet room away from a recreational area conversion disorder: Pt with new onset of blindness, what would suggest a conversion reaction? No organic correlation to symptoms Borderline personality disorder: Splitting question Client's view people as all good or all bad Bulimia pt who has eroded tooth enamel, complains of severe chest and abdominal pain. Mentions heartburn for two weeks. What should the nurse address first? Chest and abdominal pain Pt with eating disorder. What should be included in the plan of care? To weigh in everyday Teenager with self inducing vomiting. Nursing priority? Assess frequency of binging and purging behaviors Depression: Pt with major depressive disorder is not motivated and has insomnia. Best nursing action? Design a teaching plan with structured activities The male client admitted after attempted suicide due to a recent divorce. What is the source of the current depression? A sense of loss Client with history of major depressive disorder is exhibiting increased energy, to assess for suicide what would you ask? Do you still feel sad? Client very depressed and slow to respond to questions and when asked how to explain how he feels, he looks down at the table. What is the best nursing intervention? Return at a later time to talk A depressed client has only had four hours of sleep. Would you wake the client for vital signs ? NO ! Let them sleep. A depressed client sleeps all day. What would be the best nursing action? Encourage the client to get out of bed Postpartum depression: Parent of a 8 month old states that the child is not growing normally, that something is wrong with him and not right. What is the priority action? To ask if the parent wants to harm the infant A client has just given birth and is now displaying sadness, poor concentration, sleep disturbance, and tiredness. What is the priority nursing action? Suicide assessment Grief/loss/depression: Husband died and the spouse is not sleeping. Best action? Assess for depression related to grief Bipolar: Wife states that patient is spending large sums of money, not sleeping, has weight loss. Pt has a bipolar diagnosis. What would be an appropriate nursing diagnosis? Risk for violence related to impulsivity Bipolar patient tells the nurse that he needs to make some business deals. What should the nurse include in his plan of care? Delay business decisions until the mania subsides Bipolar patient who superficially cuts himself. How should you communicate? Be non-judgmental Client visits clinic and asks nurse for more lithium and Elavil to help sleep. A serum creatinine was obtained. What is the reason for the lab test? Lithium is excreted by the kidneys and creatinine is related to kidney function Schizophrenia- client isolates himself to his room, vaguely answers questions, and peeks down hallway occasionally. Which problem can the nurse anticipate? Delusions of persecution Schizophrenic patient using echolalia and is becoming more annoying. What is the best nursing intervention? Escort them to their room Schizophrenic patient refuses to eat because the food is poisoned. What is the best intrevention? Get food that is in an unopened container Substance abuse- Client with tremors, auditory hallucinations, confused, and dehydrated. What is the priority? To assess vital signs Chronic drinker with alcohol withdrawal risk. What is the best action? Seizure precautions Patient admitted with chronic alcohol abuse. What should be included in the plan of care? IV assess Patient with history of alcohol abuse, admitted for detox, and getting Ativan. What else should be administered? Vitamin B1 (Thiamine) Which statement made by a spouse of an alcoholic indicates codependency? A statement that basically makes excuses for their behavior- couldn't remember exact answer, so general idea (example:wife is making excuses) Client admitted for aspiration of material related to a suicide attempt. Highest priority? Risk for ineffective breathing 18 year old admitted with suspected drug overdose. What is the most important information to obtain from family/friends? What drug was ingested Patient with schizophrenia in a hospital with drug and alcohol abuse, is admitted for hepatitis. The nurse should consult the HCP prior to giving which medication? Acetaminophen (Tylenol) The client falls downstairs with signs and symptoms of early narcotic withdrawal. What other signs and symptoms would the nurse suspect? Agitation, sweating, and abdominal cramps Amphetamines Puts a person at high risk for myocardial infarction Intimate partner violence: which findings of the injury should the nurse include in documentation? Photographs Rape and sexual assault: A client who was raped. What is an appropriate nursing diagnosis? Decreased self-esteem due to blaming themselves for the rape Attention deficit disorder: A child has impulsiveness, hyperactivity, inappropriate attention span. What is the best nursing intervention? Administer the prescribed medications Antidepressant medication side effects (example drug: Cymbalta) Anticholinergic effects: dry mouth, blurred vision, constipation Patient is taking chlorpromazine for schizophrenia, starts to exhibit signs of tardive dyskinesia. What is the best action? Administer Benztropine (Cogentin) A patient is being administered Xanax (Alprazolam) and reports dizziness, lightheadedness, low blood pressure. What is the highest priority? Monitor vital signs Patient is prescribed buspar. Patient is concerned how long it will take for the medication to work? Normally takes 2 to 3 weeks to start working For trazodone or lidisoril: if the patient develops priapism what do you ask them about? Ask about other erectile dysfunction medications Patient is getting Depakote for mania, how do you know if this medication is working? Decrease hyperexcitable behaviors Schizophrenic patient on Haldol times two weeks. What should the nurse obtain during the initial visit? Vital signs Patient on Haldol develops tremors. Best nursing action? Call the HCP to decrease the dose Schizophrenic patient on Risperdal, exhibiting negative symptoms. Best nursing action? Give Benztropine (Cogentin) for dystonia Patient with schizophrenia getting Geodon, spouse concerned as to why this medication would be administered? Will help the patient think more clearly Patient taking Clozaril and Benztropine, and Clozaril is discontinued. What should the next nurse's action be? Call the HCP to get the Benztropine discontinued Teaching for the client about the initial of Antabuse. What info to include Should remain alcohol free 12 hours prior to the first dose Alzheimer's medications: What type of medication is Namenda (Memantine) NMDA Antagonist HESI RN MENTAL HEALTH While in group therapy, a client who is diagnosed with posttraumatic stress disorder (PTSD) is processing an experience from the war in Iraq when another client tips over a chair. What action should the nurse take when the client with PTSD falls to the floor in a fetal position? A. Confront the client who tipped over the chair about the inconsiderate behavior. B. Dismiss the other clients from the group therapy session for a 10-minute break. C. Reinforce reality to the client on the floor and remove him to a quiet space. D. Call a security code and medicate both clients with an antianxiety drug. Correct Answer: C Rationale: The client who is diagnosed with PTSD is reexperiencing the traumatic experience and needs reality reassurance (confirmation that there is no danger at this time) and reduced stimuli (C). (A, B, and D) do not consider the needs of these two clients at this time. The nurse notes multiple burns on the arms and chest of a 2-year-old Vietnamese child who is being treated for dehydration. When questioned, the child's father states that he treated the child's vomiting with the cultural practice termed coining, which resulted in burned areas. Which expected outcome statement has the highest priority? A. The child will be protected from further harm. B. The family's cultural values will be respected. C. The parents will express regret at harming their child. D. The parents will demonstrate an ability to care for burn wounds. Correct Answer: A Rationale: The nurse's highest priority is to ensure that no further harm befalls the child (A). (B, C, and D) are also important objectives but are secondary to (A). A client in an acute care facility has been taking antipsychotic medications for the past 3 days with a decrease in psychotic behaviors and no adverse reactions. On the fourth day, the client experiences an increase in blood pressure and temperature and demonstrates muscular rigidity. Which action should the nurse initiate? A. Place the client on seizure precautions and monitor frequently. B. Take the client's vital signs and notify the health care provider immediately. C. Describe the symptoms to the charge nurse and document them in the client's record. D. No action is required at this time because these are known side effects of her medications. Correct Answer: B Rationale: This is an emergency situation, and the client requires immediate management in a critical care setting (B). These symptoms are descriptive of neuroleptic malignant syndrome (NMS), an extremely serious and life-threatening reaction to neuroleptic drugs. The major symptoms of this syndrome are fever, rigidity, autonomic instability, and encephalopathy. Respiratory failure, cardiovascular collapse, arrhythmias, and/or renal failure can result in death. (A) is not indicated in this situation. (C) does not consider the seriousness of the situation. (D) is an incorrect statement. A client who recently retired is admitted to the psychiatric inpatient unit with a diagnosis of major depression. The initial nursing care plan includes the goal, "Assist client to express feelings of guilt." What is true about the goal statement referring to the client's depression? A. Implementation of the goal should be deferred until further data can be gathered. B. The depression will dissipate once the client becomes accustomed to retirement. C. Depressed clients may be unaware of guilt feelings and should be encouraged to increase selfawareness. D. Nursing goals should be approved by the treatment team before they are initiated. Correct Answer: C Rationale: Depression is associated with feelings of guilt, and clients are often not aware of these feelings (C). Awareness is the first step in dealing with guilt (or any other feeling), so the nurse's efforts should be directed toward increasing the client's awareness of feelings. Although a goal may be changed based on an evaluation of interventions to meet the goal, a goal should never be ignored (A). (B) dismisses the client's symptoms as age-related. Setting goals for the nursing care plan is a function of the nurse (D), although the nurse can collaborate with the treatment team. An individual with a known history of alcohol abuse is admitted for emergency surgery following a motor vehicle collision. The nurse includes in the client's plan of care, "Observe for signs of delirium tremens." Which early signs indicate that the client is beginning to have delirium tremens? A. Abdominal cramping and watery eyes B. Depression and fatigue C. Restlessness and confusion D. Hostility and anger Correct Answer: C Rationale: A client experiencing alcohol withdrawal often has delirium tremens (DTs), which are characterized by progressive disorientation. Initially, the client will appear restless and confused (C) and develop tachycardia, tachypnea, and diaphoresis. Hallucinations, paranoia, and seizures can also occur later in the development of DTs. (A) is indicative of withdrawal from opiates such as heroin or morphine. (B) is often seen in cocaine withdrawal. (D) is most characteristic of the paranoid client. A woman brings her 48-year-old husband to the outpatient psychiatric unit and tells the nurse that he has been sleepwalking, cannot remember who he is, and exhibits multiple personalities. These behaviors are often associated with which condition? A. Dissociative disorder B. Obsessive-compulsive disorder C. Panic disorder D. Posttraumatic stress syndrome Correct Answer: A Rationale: Sleepwalking, amnesia, and multiple personalities are examples of detaching emotional conflict from one's consciousness (A). (B) is characterized by persistent, recurrent intrusive thoughts or urges (obsessions) that are unwilled and cannot be ignored and provoke impulsive acts (compulsions), such as constant and repeated hand washing. (C) is an acute attack of anxiety characterized by personality disorganization. (D) is reexperiencing a psychologically terrifying or distressing event that is outside the usual range of human experience such as war or rape. client in the critical care unit who has been oriented suddenly becomes disoriented and fearful. Assessment of vital signs and other physical parameters reveals no significant changes, and the nurse formulates the diagnosis of Confusion related to ICU psychosis. Which intervention is best to implement based on this client's behavior? A. Move all medical equipment away from the client's bedside. B. Allay fears by teaching the client about the causes of the disease. C. Cluster care to allow for brief rest periods during the day. D. Encourage visitation by the client's family members, including the client's young children. Correct Answer: C Rationale: The best intervention is to organize care so that the client can experience rest periods (C). The critical care unit contains many lifesaving treatment modalities that offer clients an array of auditory, visual, and even painful stimuli. These stressors can result in isolation and confusion. (A) is not practical because the client may need assistance from medical equipment to survive. The client is too ill to receive teaching (B). Although (D) may be supportive, young children are routinely prohibited from critical care units because of increased risk of infectious disease transmission. At the first meeting of a group at a daycare center for older adults, the nurse asks one of the members what kinds of things the client would like to do with the group. The older adult shrugs and says, "You tell me. You're the leader." What would be the best response for the nurse to make? A. "Yes, I am the leader today. Would you like to be the leader tomorrow?" B. "Yes, I will be leading this group. What would you like to accomplish?" C. "Yes, I have been assigned to lead this group. I will be here for the next 6 weeks." D. "Yes, I am the leader. You seem angry about not being the leader yourself." Correct Answer: B Rationale: Anxiety over participation in a group and testing of the leader characteristically occur in the initial phase of group dynamics. (B) provides information and refocuses the group to defining its function. (A) is manipulative bargaining. (C) does not focus the group on its purpose or task. (D) is interpreting the client's feelings and is almost challenging. The nurse is assessing a young client admitted to the psychiatric unit for acute depression related to a recent divorce. Which statement is most indicative of a client suffering from depression? A. "I'm not very pretty or likeable." B. "I've lost 20 pounds in the past month." C. "I like to keep things to myself." D. "I think everyone is out to get me." Correct Answer: A Rationale: Feelings of hopelessness (A) are characteristic of one who is depressed. Although (B) might be indicative of depression, further assessment would be required to rule out an organic cause before attributing the statement to depression. (C and D) are indicative of a paranoid personality. The nurse develops a plan of care for a client with symptoms of paranoia and psychosis. The priority nursing diagnosis is Impaired social interactions related to inability to trust. Which intervention is most important for the nurse to implement? A. Greet the client by first name during each social interaction. B. Determine if the client is experiencing auditory hallucinations. C. Introduce the client to peers on the unit as soon as possible. D. Assign the client to a group about developing social skills. Correct Answer: A Rationale: The most important nursing intervention is to greet the client by name (A) and provide short frequent contact to establish trust. The presence of auditory hallucinations can affect social interactions (B), but is not a priority intervention. (C and D) are effective interventions after individual rapport has been established with the client. On admission, a highly anxious client is described as delusional. Delusions are most likely to occur with which disorder? A. Dissociative disorders B. Personality disorders C. Anxiety disorders D. Psychotic disorders Correct Answer: D Rationale: Delusions are false beliefs characteristic of psychosis (D). Delusions are generally not characteristic of (A, B, and C). On admission, a depressed client tells the nurse, "I can't eat because my tongue is rubber." Which is the best action for the nurse to implement? A. Provide packaged foods for the client to eat. B. Begin the client on total parenteral nutritional (TPN) therapy. C. Provide a well-balanced liquid diet for the client. D. No action is necessary because the client will eat when hungry. Correct Answer: C Rationale: The nurse should strive to provide a safe environment (adequate nutrition is part of a safe environment) and should not argue with the client's delusions. (C) is the least invasive while providing nutrition that does not argue with the client's delusion. (A) is given to those with paranoid delusions. (B) is invasive and would be used as a last resort. (C) should be tried first. This client's delusion could be life threatening and should not be ignored (D). A 38-year-old client is admitted with a diagnosis of paranoid schizophrenia. When the lunch tray is brought to the room, the client refuses to eat and tells the nurse, "I know you are trying to poison me with that food." Which response by the nurse is the most therapeutic? A. "I'll leave your tray here. I am available if you need anything else." B. "You're not being poisoned. Why do you think someone is trying to poison you?" C. "No one on this unit has ever died from poisoning. You're safe here." D. "I will talk to your health care provider about the possibility of changing your diet." Correct Answer: A Rationale: (A) is the best choice because the nurse does not argue with the client or demand that that the client eat but offers support by agreeing to be there if needed, which provides an open, rather than closed, response to the client's statement. (B and C) are challenging the client's delusions, and (B) asks "why." Probing questions, which start with "why," are usually not therapeutic communication for a psychotic client. (D) has not addressed the actual problem—that is, the client's delusions. During a home visit, a client with schizophrenia reports hearing voices that tell the client to walk in the middle of the street. The nurse records several statements made by the client. Based on which statement should the nurse determine that the client needs hospitalization? A. "Sometimes I take an extra one of my pills when I hear the voices." B. "The voices are louder when I forget to take my medication. " C. "No matter what I do, I cannot make the voices go away. " D. "I just try to tell the voices to stop when they bother me. " Correct Answer: C Rationale: Hospitalization is needed if the client continues to hear voices telling the client to do things that can cause self-harm (C). (A or B) do not require hospitalization unless symptoms become severe. The client should continue symptom management strategies (D) to prevent hospitalization. Which behavior indicates to the nurse that a client with paranoid ideas is improving? A. Arrives on time for all activities B. Talks more openly about plans to protect his possessions C. Aggressively uses the punching bag in the gym D. Discusses his feelings of anxiety with the nurse Correct Answer: D Rationale: Anxious feelings increase paranoid ideation. If the client is able to discuss these feelings (D), then the client is improving because of fewer paranoid ideas. (A) would indicate that a client with depression or one who is passive-aggressive is improving. (B) indicates feelings of paranoia. (C) indicates the release of anger, and "anger turned inward" is sometimes used as a definition for depression. A 25-year-old client has been particularly restless and the nurse finds the client trying to leave the psychiatric unit. The client tells the nurse, "Please let me go! I must leave because the secret police are after me." Which response is best for the nurse to make? A. "No one is after you. You're safe here." B. "You'll feel better after you have rested." C. "I know you must feel lonely and frightened." D. "Come with me to your room, and I will sit with you." Rationale: (D) is the best response because it offers support without judgment or demands. (A) is challenging the client's delusion. (B) is offering false reassurance. (C) is a violation of therapeutic communication because the nurse is telling the client how she or he feels (frightened and lonely), rather than allowing the client to describe his or her own feelings. Hallucinating and delusional clients are not capable of discussing their feelings, particularly when they perceive a crisis. A 35-year-old client admitted to the psychiatric unit of an acute care hospital tells the nurse that someone is trying to poison her. The client's delusions are most likely related to which factor? A. Authority issues in childhood B. Anger about being hospitalized C. Low self-esteem D. Phobia of food Rationale: Delusional clients have difficulty with trust and have low self-esteem (C). Nursing care should be directed at building trust and promoting positive self-esteem. Activities with limited concentration and no competition should be encouraged to build self-esteem. (A, B, and D) are not specifically related to the development of delusions. The nurse admits a client with depression to the mental health unit. The client reports difficulty concentrating, has lost 10 pounds in 2 weeks, and is sleeping 12 hours a day. Which outcome is most important for the client to meet by discharge? A. Tries to interact with a few peers and staff B. Reports feeling better and less depressed C. Sits attentively with peers in group therapy D. Easily awakens for morning medications Rationale: The client is experiencing symptoms of depression, and the outcome by discharge for this client would be that the client reports feeling better and less depressed (B). The client may interact with peers and staff (A) and sit attentively in groups (C) without any improvement in depression. Difficulty awakening is usually caused by the medication regimen for depression, so awakening (D) is not an indication of improvement. A client begins taking an atypical antipsychotic medication. The nurse must provide informed consent and education about common medication side effects. Which client education will be most important? A. Maintain a balanced diet and adequate exercise.