HESI FUNDAMENTALS EXAM 1
the purpose of therapeutic interaction - CORRECT ANSWER-to allow the client to
autonomy to make choices when appropriate. keep statements value-free, advice free,
and reassurance-free
what action should the nurse take in a psychiatric situation when the client describes a
physical problem? - CORRECT ANSWER-assess. example: if a client has
schizophrenia complains of chest pain take their blood pressure
basic communication principles - CORRECT ANSWER-establish trust, nonjudgemental
attitude,active listening, offer self, accept client's feelings, validate client's statements,
matter of fact approach
nausea is a common complaint after ECT - CORRECT ANSWER-vomiting by an
unconscious can lead to aspiration. maintain a paten airway
common physiological responses to anxiety - CORRECT ANSWER-increased heart
rate, and blood pressure, rapid shallow respirations, dry mouth, tight feeling in throat,
tremors, muscle twitching, anorexia, urinary frequency, palmar sweating
nurse-client anxiety - CORRECT ANSWER-anxiety is contagious, nurse needs to asses
on anxiety level and remain calm. it helps gain control, decrease anxiety, and increase
feelings of security
desensitization - CORRECT ANSWER-is the nursing intervention for phobia disorders. -
-assess client to recognize the factors associated with feared stimuli.
-teach and practice with client alternative coping strategies
-expose client to feared stimuli
-provide positive reinforcement
the nurse should place an anxious client where there are reduced environmental stimuli
- CORRECT ANSWER-quiet area of the unit away from the nurse's station
the best time for interaction with a client is at the completion of the performed ritual -
CORRECT ANSWER-the client's anxiety is lowest at this time and its an optimal time
for learning
compulsive acts are used in response to anxiety, which may or may not be related to
the obsession. its the nurse's responsibility help alleviate anxiety - CORRECT
ANSWER-its the nurse's responsibility help alleviate anxiety, interfering will increase the
anxiety
,as long as the client's acts are free of violence: nurse should.... - CORRECT ANSWER--
actively listen to the clients obsessive themes
-acknowledge the effects that ritualistic acts have on the client
-demonstrate empathy
-avoid being judgmental
ford clients with PTSD, the nurse should.... - CORRECT ANSWER--actively listen to
client's stories of experiences surrounding the traumatic event
-assess suicide risk
-assist client to develop objectivity about the event and problem solve regarding
possible means of controlling anxiety related to the event
-encourage group therapy with other clients who have experienced the same traumatic
event
be aware of your own feelings when dealing with this somatoform clients. - CORRECT
ANSWER-the pain is real to the person experiencing it
theses disorders cannot be explained medically, it results from internal conflict. the
nurse should... - CORRECT ANSWER--acknowledge the symptom or complaint
-reaffirm that diagnostic test results reveal no organic pathology
-determine the secondary gains acquired by the client
avoid giving clients with dissociative disorders too much information about past events
at one time - CORRECT ANSWER-the various types of amnestic that accompany
dissociative disorders provide protection from pain and too much to soon can cause
decompensation
personality disorders are long standing behavioral traits that are maladaptive responses
to anxiety and that cause difficulty in relating to and working with other individuals -
CORRECT ANSWER-persons with personality disorders are usually comfortable with
their disorders and believe that they are right and the world is wrong and have little
motivation
people with anorexia gain pleasure from providing others with food and watching them
eat - CORRECT ANSWER-these behaviors reinforce their perception of self-control.
don not allow these clients to plan or prepare food for unit-based activities
individuals with Bulimia often use syrup of ipecac to induce vomiting. if ipecac is not
vomited and is absorbed, cardiotoxicity may occur and cause conduction disturbances,
cardiac dysrhythmias, fatal myocarditis, and circulatory failure - CORRECT ANSWER-
because heart failure is not usually seen in this age group, it is often overlooked. assess
for edema and listen to breath sounds
physical assessment and nutritional support are a priority, the physiological implication
are great. nursing interventions should increase self-esteem and develop a positive
, body image. - CORRECT ANSWER-family therapy is most effective because issues of
control are common in these (eating disorders.) therapy is usually long term
the most important s/s of depression are a depressed mood with a loss of interest in the
pleasures in life - CORRECT ANSWER-the client has a sustained loss
s/s of depression - CORRECT ANSWER--significant change in appetite
-insomnia
-fatigue or lack of energy
-feelings of hopelessness
-loss of ability to concentrate
-preoccupation with death or suicide
depressed clients have difficulty hearing and accepting compliments because of their
lowered self-concept - CORRECT ANSWER-comment on signs of improvement by
noting behavior
the nurse knows depressed clients are improving when they - CORRECT ANSWER-
begin to take an interest in their appearance or begin to perform self-care activities
the nurse should suspect an imminent suicide attempt if a depressed client becomes
"better" - CORRECT ANSWER-be aware a happy affect may signify the the client feels
relieved that a plan has been made and is prepared for the suicide attempt
when dealing with a depressed client the nurse should assist with personal hygiene
tasks and encourage the client to initiate grooming activities even when they dont feel
like doing so - CORRECT ANSWER-this helps to promote self-esteem and a sense of
control
nursing intervention for depressed client - CORRECT ANSWER-sit quietly with the
client, offering your support with your presence
side effects of antianxiety drugs - CORRECT ANSWER-sedation, drowsiness
s/e of antidepressants drugs - CORRECT ANSWER-anticholinergic effects, postural
hypotension
s/e MAO inhibitors - CORRECT ANSWER-hypertensive crisis
lithium requires renal function assessment and monitoring - CORRECT ANSWER-
phenothiazines cause EPS (tardic dyskinesia can be permanent)
phenothiazines cause photosensitivity so client must wear protective clothing and
sunglasses - CORRECT ANSWER-MAO inhibitors require dietary restrictions to prevent
hypertensive crisis
the purpose of therapeutic interaction - CORRECT ANSWER-to allow the client to
autonomy to make choices when appropriate. keep statements value-free, advice free,
and reassurance-free
what action should the nurse take in a psychiatric situation when the client describes a
physical problem? - CORRECT ANSWER-assess. example: if a client has
schizophrenia complains of chest pain take their blood pressure
basic communication principles - CORRECT ANSWER-establish trust, nonjudgemental
attitude,active listening, offer self, accept client's feelings, validate client's statements,
matter of fact approach
nausea is a common complaint after ECT - CORRECT ANSWER-vomiting by an
unconscious can lead to aspiration. maintain a paten airway
common physiological responses to anxiety - CORRECT ANSWER-increased heart
rate, and blood pressure, rapid shallow respirations, dry mouth, tight feeling in throat,
tremors, muscle twitching, anorexia, urinary frequency, palmar sweating
nurse-client anxiety - CORRECT ANSWER-anxiety is contagious, nurse needs to asses
on anxiety level and remain calm. it helps gain control, decrease anxiety, and increase
feelings of security
desensitization - CORRECT ANSWER-is the nursing intervention for phobia disorders. -
-assess client to recognize the factors associated with feared stimuli.
-teach and practice with client alternative coping strategies
-expose client to feared stimuli
-provide positive reinforcement
the nurse should place an anxious client where there are reduced environmental stimuli
- CORRECT ANSWER-quiet area of the unit away from the nurse's station
the best time for interaction with a client is at the completion of the performed ritual -
CORRECT ANSWER-the client's anxiety is lowest at this time and its an optimal time
for learning
compulsive acts are used in response to anxiety, which may or may not be related to
the obsession. its the nurse's responsibility help alleviate anxiety - CORRECT
ANSWER-its the nurse's responsibility help alleviate anxiety, interfering will increase the
anxiety
,as long as the client's acts are free of violence: nurse should.... - CORRECT ANSWER--
actively listen to the clients obsessive themes
-acknowledge the effects that ritualistic acts have on the client
-demonstrate empathy
-avoid being judgmental
ford clients with PTSD, the nurse should.... - CORRECT ANSWER--actively listen to
client's stories of experiences surrounding the traumatic event
-assess suicide risk
-assist client to develop objectivity about the event and problem solve regarding
possible means of controlling anxiety related to the event
-encourage group therapy with other clients who have experienced the same traumatic
event
be aware of your own feelings when dealing with this somatoform clients. - CORRECT
ANSWER-the pain is real to the person experiencing it
theses disorders cannot be explained medically, it results from internal conflict. the
nurse should... - CORRECT ANSWER--acknowledge the symptom or complaint
-reaffirm that diagnostic test results reveal no organic pathology
-determine the secondary gains acquired by the client
avoid giving clients with dissociative disorders too much information about past events
at one time - CORRECT ANSWER-the various types of amnestic that accompany
dissociative disorders provide protection from pain and too much to soon can cause
decompensation
personality disorders are long standing behavioral traits that are maladaptive responses
to anxiety and that cause difficulty in relating to and working with other individuals -
CORRECT ANSWER-persons with personality disorders are usually comfortable with
their disorders and believe that they are right and the world is wrong and have little
motivation
people with anorexia gain pleasure from providing others with food and watching them
eat - CORRECT ANSWER-these behaviors reinforce their perception of self-control.
don not allow these clients to plan or prepare food for unit-based activities
individuals with Bulimia often use syrup of ipecac to induce vomiting. if ipecac is not
vomited and is absorbed, cardiotoxicity may occur and cause conduction disturbances,
cardiac dysrhythmias, fatal myocarditis, and circulatory failure - CORRECT ANSWER-
because heart failure is not usually seen in this age group, it is often overlooked. assess
for edema and listen to breath sounds
physical assessment and nutritional support are a priority, the physiological implication
are great. nursing interventions should increase self-esteem and develop a positive
, body image. - CORRECT ANSWER-family therapy is most effective because issues of
control are common in these (eating disorders.) therapy is usually long term
the most important s/s of depression are a depressed mood with a loss of interest in the
pleasures in life - CORRECT ANSWER-the client has a sustained loss
s/s of depression - CORRECT ANSWER--significant change in appetite
-insomnia
-fatigue or lack of energy
-feelings of hopelessness
-loss of ability to concentrate
-preoccupation with death or suicide
depressed clients have difficulty hearing and accepting compliments because of their
lowered self-concept - CORRECT ANSWER-comment on signs of improvement by
noting behavior
the nurse knows depressed clients are improving when they - CORRECT ANSWER-
begin to take an interest in their appearance or begin to perform self-care activities
the nurse should suspect an imminent suicide attempt if a depressed client becomes
"better" - CORRECT ANSWER-be aware a happy affect may signify the the client feels
relieved that a plan has been made and is prepared for the suicide attempt
when dealing with a depressed client the nurse should assist with personal hygiene
tasks and encourage the client to initiate grooming activities even when they dont feel
like doing so - CORRECT ANSWER-this helps to promote self-esteem and a sense of
control
nursing intervention for depressed client - CORRECT ANSWER-sit quietly with the
client, offering your support with your presence
side effects of antianxiety drugs - CORRECT ANSWER-sedation, drowsiness
s/e of antidepressants drugs - CORRECT ANSWER-anticholinergic effects, postural
hypotension
s/e MAO inhibitors - CORRECT ANSWER-hypertensive crisis
lithium requires renal function assessment and monitoring - CORRECT ANSWER-
phenothiazines cause EPS (tardic dyskinesia can be permanent)
phenothiazines cause photosensitivity so client must wear protective clothing and
sunglasses - CORRECT ANSWER-MAO inhibitors require dietary restrictions to prevent
hypertensive crisis
