Menatal Health/BH Hesi V2:Questions and Answers (Rationate)100%Guaranteed
a 19 year old female client with a diagnosis of anorexia nervosa wants to help serve dinner trays to other
clients on a psychiatric unit.. what action should the nurse take
A. Encourage the client self-motivation by asking her to pass trays for the rest of the week. B. Provide an
additional challenge by asking the client to help feed the older clients.C. Suggest another way or this client to
participate in the unit's activities.D. Tell the client that hospital guidelines allow only staff to pass the trays. -
anssuggest another way for this client to participate in unit activities: anorexics gain pleasure from providing
others with food and watching them eat.. such behaviors reinforce their perception of self control.. these
clients should not be allowed to plan or prepare food for unit activities and their desires to do so should be
redirected
a 22 year old male client is admitted to the emergency center following a suicide attempt.. his records reveal
that this is his third suicide attempt in the past two years.. he is conscious, but does not respond to verbal
commands for treatment.. which assessment finding should prompt the nurse to prepare the client for gastric
lavage
- He ingested the drug 3 hours prior to admission to the emergency center.
- The family reports that he took an entire bottle of acetaminophen (Tylenol).
- He is unresponsive to instructions and is unable to cooperate with emetic therapy.
- Those with repeated suicide attempts desire punishment to relieve their guilt. - anshe is unresponsive to
instructions and is unable to cooperate with emetic therapy: bc the client is unable to follow instructions,
emetic therapy would be very difficult to implement and gastric lavage would be necessary
a 25 year old female client has been particularly restless and the nurse finds her trying to leave the psychiatric
unit.. she tells the nurse "please let me go! i must leave bc the secret police are after me".. which response is
best for the nurse to make
- No one is after you, you're safe here.
- You'll feel better after you have rested.
- I know you must feel lonely and frightened.
- Come with me to your room and I will sit with you. - anscome with me to your room and i will sit with you:
,this is the best response bc it offers support without judgement or demands
a 27 year old female client is admitted to the psychiatric hospital with a diagnosis of bipolar disorder, manic
phase.. she is demanding and active.. which intervention should the nurse include in this clients plan of care
A. Schedule her to attend various group activities.B. Reinforce her ability to make her own decisions.C.
Encourage her to identify feelings of anger.D. Provide a structural environment with little stimuli. - ansprovide a
structured environment with little stimuli: clients in the manic phase of a bipolar disorder require decreased
stimuli and a structured environment
a 30 year old sales manager tells the nurse "i am thinking about a job change. i don't feel like i am living up to
my potential." which of maslows developmental stages is the sales manager attempting to achieve
A. Self-Actualization
B. Loving and Belonging
C. Basic Needs
D. Safety and Security - ansself actualization: self actualization is the highest level of maslows developmental
stages, which is an attempt to fulfill ones full potential.. loving and belonging is identifying support systems..
basic needs is the first level of maslows developmental stages and is the foundation upon which higher needs
rest.. individuals who feel safe and secure in their environment perceive themselves as having physical safety
and lack fear of harm
a 35 year old male client on the psychiatric ward of a general hospital believes that someone is trying to poison
him.. the nurse understands that a clients delusions are most likely related to his
A. Early childhood experiences involving authority issues. B. Anger about being hospitalized.C. Low self-
esteemD. Phobia fear of food - anslow self esteem: psychotic clients have difficulty with trust and have low self
esteem.. nursing care should be directed at building trust and promoting positive self esteem.. activities with
limited concentration and no competition should be encouraged in order to build self esteem
a 35 year old male client who has been hospitalized for two weeks for chronic paranoia continues to state that
someone is trying to steal his clothing.. which action should the nurse implement
,- Encourage the client to actively participate in assigned activities on the unit.
- Place a lock on the client's closet.
- Ignore the client's paranoid ideation to extinguish these behaviors.
- Explain to the client that his suspicions are false. - ansencourage the client to actively participate in assigned
activities on the unit: diverting the clients attention from paranoid ideation and encouraging him to complete
assignments can be helpful in assisting him to develop a positive self image
a 35 year old married woman works full time in a factory and has been absent from work for three days at a
time on several occasions.. each time she returns to work, she wears dark glasses to cover facial bruising.. her
supervisor refers her to the occupational health nurse.. what assessment question is most important for the
nurse to initially use
A. Do you drink excessively?B. Did your husband beat you?C. How did this happen to you? D. What did you do
to deserve this? - anshow did this happen to you: domestic violence can present in several forms, including
sexual, physical, mental, and neglect.. the victim of spousal abuse is often frightened of may feel at fault about
the abuse, so a therapeutic relationship should be established with the client using non judgmental, open
ended questions, so the client is comfortable to disclose details about the injury, if abuse is suspected
a 38 year old female client is admitted with a diagnosis of paranoid schizophrenia.. when her tray is brought to
her, she refuses to eat and tells the nurse, "i know you are trying to poison me with that food".. which
response is most appropriate for the nurse to make
A. I'll leave your tray here. I am available if you need anything elseB. You are 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 are safe here.D.
I will talk to your healthcare provider about the possibility of changing your diet - ansill leave your tray here.. i
am available if you need anything else: this is the best response.. the nurse does not argue with the client nor
demand that she eat, but offers support by agreeing to "be there if needed" (to warm the food)
a 40 year old male client diagnosed with schizophrenia and alcohol dependence has not had any visitors or
phone calls since admission.. he reports he has no family that cares about him and was living on the streets
prior to this admission.. according to ericksons theory of psychosocial development, which stage is the client in
at this time
, - Isolation.
- Stagnation.
- Despair.
- Role confusion. - ansstagnation: the client is in ericksons generativity vs. stagnation stage (ages 24-45), and
meeting the task includes maintaining intimate relationships and moving toward developing a family
a 45 year old female client is admitted to the psychiatric unit for evaluation.. her husband states that she has
been reluctant to leave home for the last six months.. the client has not gone to work for a month and has
been terminated from her job.. she has not left the house since that time.. this client is displaying symptoms of
what condition
A. Claustrophobia B. AcrophobiaC. AgoraphobiaD. Post-traumatic stress disorder - ansagoraphobia:
agoraphobia is the fear of crowds or being in an open place.. remember a phobia is an unrealistic fear which is
associated with severe anxiety
a 45 year old male client tells the nurse that he used to believe that he was jesus christ, but now he knows he is
not.. which response is best for the nurse to make
A. Did you really believe you were Jesus Christ?B. I think you're getting wellC. Others have had similar thoughts
when under stressD. Why did you think you were Jesus Christ? - ansothers have had similar thoughts when
under stress: this response offers support by assuring the client that others have suffered as he has (also the
principle on which AA acts)
a 46 year old female client has been on antipsychotic neuroleptics for the past three days.. she has had a
decrease in psychotic behavior and appears to be responding well to the medication.. on the fourth day, the
clients blood pressure increases, she becomes pale and febrile, and demonstrates muscular rigidity.. which
action should the nurse initiate
A. Place the client on seizure precautions and monitor carefully. B. Immediately transfer the client to ICU.C.
Describe the symptoms to the charge nurse and record on the clients chart.D. No action is required at this time
as these are known side effects of such drugs. - ansimmediately transfer the client to the ICU: these symptoms
are descriptive of neuroleptic malignant syndrome (NMS) which is an extremely serious/life threatening
reaction to the neuroleptic drugs.. the major symptoms of this syndrome are fever, rigidity, autonomic
instability, and encephalopathy.. respiratory failure, cardiovascular collapse, arrhythmias, and/or renal failure
a 19 year old female client with a diagnosis of anorexia nervosa wants to help serve dinner trays to other
clients on a psychiatric unit.. what action should the nurse take
A. Encourage the client self-motivation by asking her to pass trays for the rest of the week. B. Provide an
additional challenge by asking the client to help feed the older clients.C. Suggest another way or this client to
participate in the unit's activities.D. Tell the client that hospital guidelines allow only staff to pass the trays. -
anssuggest another way for this client to participate in unit activities: anorexics gain pleasure from providing
others with food and watching them eat.. such behaviors reinforce their perception of self control.. these
clients should not be allowed to plan or prepare food for unit activities and their desires to do so should be
redirected
a 22 year old male client is admitted to the emergency center following a suicide attempt.. his records reveal
that this is his third suicide attempt in the past two years.. he is conscious, but does not respond to verbal
commands for treatment.. which assessment finding should prompt the nurse to prepare the client for gastric
lavage
- He ingested the drug 3 hours prior to admission to the emergency center.
- The family reports that he took an entire bottle of acetaminophen (Tylenol).
- He is unresponsive to instructions and is unable to cooperate with emetic therapy.
- Those with repeated suicide attempts desire punishment to relieve their guilt. - anshe is unresponsive to
instructions and is unable to cooperate with emetic therapy: bc the client is unable to follow instructions,
emetic therapy would be very difficult to implement and gastric lavage would be necessary
a 25 year old female client has been particularly restless and the nurse finds her trying to leave the psychiatric
unit.. she tells the nurse "please let me go! i must leave bc the secret police are after me".. which response is
best for the nurse to make
- No one is after you, you're safe here.
- You'll feel better after you have rested.
- I know you must feel lonely and frightened.
- Come with me to your room and I will sit with you. - anscome with me to your room and i will sit with you:
,this is the best response bc it offers support without judgement or demands
a 27 year old female client is admitted to the psychiatric hospital with a diagnosis of bipolar disorder, manic
phase.. she is demanding and active.. which intervention should the nurse include in this clients plan of care
A. Schedule her to attend various group activities.B. Reinforce her ability to make her own decisions.C.
Encourage her to identify feelings of anger.D. Provide a structural environment with little stimuli. - ansprovide a
structured environment with little stimuli: clients in the manic phase of a bipolar disorder require decreased
stimuli and a structured environment
a 30 year old sales manager tells the nurse "i am thinking about a job change. i don't feel like i am living up to
my potential." which of maslows developmental stages is the sales manager attempting to achieve
A. Self-Actualization
B. Loving and Belonging
C. Basic Needs
D. Safety and Security - ansself actualization: self actualization is the highest level of maslows developmental
stages, which is an attempt to fulfill ones full potential.. loving and belonging is identifying support systems..
basic needs is the first level of maslows developmental stages and is the foundation upon which higher needs
rest.. individuals who feel safe and secure in their environment perceive themselves as having physical safety
and lack fear of harm
a 35 year old male client on the psychiatric ward of a general hospital believes that someone is trying to poison
him.. the nurse understands that a clients delusions are most likely related to his
A. Early childhood experiences involving authority issues. B. Anger about being hospitalized.C. Low self-
esteemD. Phobia fear of food - anslow self esteem: psychotic clients have difficulty with trust and have low self
esteem.. nursing care should be directed at building trust and promoting positive self esteem.. activities with
limited concentration and no competition should be encouraged in order to build self esteem
a 35 year old male client who has been hospitalized for two weeks for chronic paranoia continues to state that
someone is trying to steal his clothing.. which action should the nurse implement
,- Encourage the client to actively participate in assigned activities on the unit.
- Place a lock on the client's closet.
- Ignore the client's paranoid ideation to extinguish these behaviors.
- Explain to the client that his suspicions are false. - ansencourage the client to actively participate in assigned
activities on the unit: diverting the clients attention from paranoid ideation and encouraging him to complete
assignments can be helpful in assisting him to develop a positive self image
a 35 year old married woman works full time in a factory and has been absent from work for three days at a
time on several occasions.. each time she returns to work, she wears dark glasses to cover facial bruising.. her
supervisor refers her to the occupational health nurse.. what assessment question is most important for the
nurse to initially use
A. Do you drink excessively?B. Did your husband beat you?C. How did this happen to you? D. What did you do
to deserve this? - anshow did this happen to you: domestic violence can present in several forms, including
sexual, physical, mental, and neglect.. the victim of spousal abuse is often frightened of may feel at fault about
the abuse, so a therapeutic relationship should be established with the client using non judgmental, open
ended questions, so the client is comfortable to disclose details about the injury, if abuse is suspected
a 38 year old female client is admitted with a diagnosis of paranoid schizophrenia.. when her tray is brought to
her, she refuses to eat and tells the nurse, "i know you are trying to poison me with that food".. which
response is most appropriate for the nurse to make
A. I'll leave your tray here. I am available if you need anything elseB. You are 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 are safe here.D.
I will talk to your healthcare provider about the possibility of changing your diet - ansill leave your tray here.. i
am available if you need anything else: this is the best response.. the nurse does not argue with the client nor
demand that she eat, but offers support by agreeing to "be there if needed" (to warm the food)
a 40 year old male client diagnosed with schizophrenia and alcohol dependence has not had any visitors or
phone calls since admission.. he reports he has no family that cares about him and was living on the streets
prior to this admission.. according to ericksons theory of psychosocial development, which stage is the client in
at this time
, - Isolation.
- Stagnation.
- Despair.
- Role confusion. - ansstagnation: the client is in ericksons generativity vs. stagnation stage (ages 24-45), and
meeting the task includes maintaining intimate relationships and moving toward developing a family
a 45 year old female client is admitted to the psychiatric unit for evaluation.. her husband states that she has
been reluctant to leave home for the last six months.. the client has not gone to work for a month and has
been terminated from her job.. she has not left the house since that time.. this client is displaying symptoms of
what condition
A. Claustrophobia B. AcrophobiaC. AgoraphobiaD. Post-traumatic stress disorder - ansagoraphobia:
agoraphobia is the fear of crowds or being in an open place.. remember a phobia is an unrealistic fear which is
associated with severe anxiety
a 45 year old male client tells the nurse that he used to believe that he was jesus christ, but now he knows he is
not.. which response is best for the nurse to make
A. Did you really believe you were Jesus Christ?B. I think you're getting wellC. Others have had similar thoughts
when under stressD. Why did you think you were Jesus Christ? - ansothers have had similar thoughts when
under stress: this response offers support by assuring the client that others have suffered as he has (also the
principle on which AA acts)
a 46 year old female client has been on antipsychotic neuroleptics for the past three days.. she has had a
decrease in psychotic behavior and appears to be responding well to the medication.. on the fourth day, the
clients blood pressure increases, she becomes pale and febrile, and demonstrates muscular rigidity.. which
action should the nurse initiate
A. Place the client on seizure precautions and monitor carefully. B. Immediately transfer the client to ICU.C.
Describe the symptoms to the charge nurse and record on the clients chart.D. No action is required at this time
as these are known side effects of such drugs. - ansimmediately transfer the client to the ICU: these symptoms
are descriptive of neuroleptic malignant syndrome (NMS) which is an extremely serious/life threatening
reaction to the neuroleptic drugs.. the major symptoms of this syndrome are fever, rigidity, autonomic
instability, and encephalopathy.. respiratory failure, cardiovascular collapse, arrhythmias, and/or renal failure
