Mental Health Hesi WITH COMPLETE SOLUTIONS

A client who was admitted two days earlier to a drug rehabilitation unit tells the nurse, "I'm going to do what you people tell me to do so I can get out of here and get a job." What is the most accurate interpretation of this client's statement? A The treatment program is effective and the client is highly motivated. B. Defense mechanisms are being used to decrease anxiety. C. Manipulation is being used to achieve the client's personal goals. D. The client has insight into his behaviors, so privileges should be given. - correct answersc. Manipulation is being used to achieve the client's personal goals. Drug abusers and patients with antisocial behaviors tend to be manipulative, so option C is the best interpretation of the client's statement at this time in the client's treatment. He has been in treatment only 2 days, which is not enough time to benefit from the program, so options A and D are highly unlikely. Although defense mechanisms are frequently used to decrease anxiety, this statement is more likely because of option C. The nurse encounters a client with bipolar disorder in an aggressive state. What is the priority nursing action for this client? A. State to the client, "You need to settle down now!" B. Say, "If you throw that lamp you will need to stay in your room for 1 hour." C. Call an alert to summon security and prepare a sedative. D. Place the client in a restraint vest and in a quiet room. - correct answersb. Say, "If you throw that lamp you will need to stay in your room for 1 hour." Rationale:The nurse needs to indicate to the client the consequences of aggressive behavior. Stating you need to settle down is nontherapeutic for the aggressive client. Calling security can precipitate more agitation. A restraint vest and a quiet room is a last resort for the aggressive client and should be used only when the client is at risk for harm to self or others. There is no indication in the stem that there is a risk for harm, only aggression. A 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 nursing action is best for 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 answersc. Cluster care to allow for brief rest periods during the day. Rationale: The best intervention is to organize care so that the client can experience rest periods. 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. Option A is not practical because the client may need assistance from medical equipment to survive. The client is too ill to receive teaching (Option B). Although option D may be supportive, young children are routinely prohibited from critical care units because of the increased risk of infectious disease transmission. The nurse is talking to a client with heightened anxiety. What actions will the nurse include when providing care for this client? (Select all that apply.) A. Ask, "Do you have any idea what happened to increase your anxiety level?" B. Encourage the client to play an individual player card game, like solitaire. C. Have the client work with others in the kitchen to prepare an afternoon snack. D. Have the client review recent events that may have triggered the change. E. State, "Tell me what you are thinking and feeling now." - correct answersA. Ask, "Do you have any idea what happened to increase your anxiety level?" C. Have the client work with others in the kitchen to prepare an afternoon snack. D. Have the client review recent events that may have triggered the change. Rationale:The nurse must attempt to solicit the preceding events and feelings prior to the increase in anxiety. Playing solitaire does not include any therapeutic actions by the nurse. Having the client work with others may trigger even more anxiety, especially if the root of the anxiety is one of the others in the kitchen. 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 self- awareness. D. Nursing goals should be approved by the treatment team before they are initiated. - correct answersc. Depressed clients may be unaware of guilt feelings and should be encouraged to increase self- awareness. Rationale: Depression is associated with feelings of guilt, and clients are often not aware of these feelings. Awareness is the first step in dealing with the 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. Option B dismisses the client's symptoms as age-related. Setting goals for the nursing care plan is a function of the nurse, although the nurse can collaborate with the treatment team. A client mumbles out loud regardless if anyone else is talking, and the client also mumbles in group when others are talking. The nurse determines that the client is experiencing hallucinations. Which action should the nurse take first? A. Respond to the client's feelings rather than illogical thoughts. B. Identify beliefs and thoughts about what the client is experiencing. C. Provide the client with the hope that the voices will eventually go away. D. Ask the client how she has previously managed the voices. - correct answersd. Ask the client how she has previously managed the voices. Rationale: The nurse should promote symptom management and determine how the client previously managed the voices. Options A and B are interventions that are useful with clients who are experiencing delusions. Option C is important, but the most important intervention is to promote symptom management. A middle-aged client tells the clinic nurse, "I'm again starting to feel overwhelmed and anxious with all my responsibilities. I don't know what to do." What is the nurse's best response? A. "Describe in more detail your feelings about being overwhelmed." B. "Why don't you give up some of your commitments?" C. "What has worked for you in the past?" D.