Psych/Mental Health Exit HESI - Saunders
A purchaser admitted to a mental health unit for remedy of psychotic behavior spends hours on
the locked exit door shouting, "Let me out. There's not anything incorrect with me. I don't belong
right here." What defense mechanism is the consumer imposing?
1. Denial
2. Projection
3. Regression
four. Rationalization - ANS-1. Denial
Rationale:
Denial is refusal to confess to a painful truth, that's handled as if it does not exist. In projection,
a person unconsciously rejects emotionally unacceptable capabilities and attributes them to
different persons, gadgets, or conditions. Regression allows the purchaser to go back to an in
advance, greater comforting, despite the fact that much less mature, way of behaving.
Rationalization is justifying illogical or unreasonable ideas, actions, or feelings via growing
perfect causes that satisfy the teller and the listener.
A customer being seen in the emergency branch straight away after being sexually assaulted
seems calm and managed. The nurse analyzes this conduct as indicating which protection
mechanism?
1. Denial
2. Projection
three. Rationalization
four. Intellectualization - ANS-1. Denial
Rational:
Denial is refusal to admit to a painful truth and can be a reaction with the aid of a sufferer of
sexual abuse. In this situation the client isn't always acknowledging the trauma of the assault
either verbally or nonverbally. Projection is transferring one's inner feelings, thoughts, and
unacceptable ideas and tendencies to someone else. Rationalization is justifying the
unacceptable attributes about oneself. Intellectualization is the immoderate use of abstract
questioning or generalizations to decrease painful questioning.
A consumer involves the emergency department after an attack and is extraordinarily agitated,
trembling, and hyperventilating. What is the priority nursing action for this consumer?
1. Begin to teach relaxation strategies.
2. Encourage the purchaser to speak about the assault.
3. Remain with the purchaser till the tension decreases.
,4. Place the purchaser in a quiet room on my own to decrease stimulation. - ANS-three. Remain
with the purchaser till the anxiety decreases.
Rationale:
This customer is in a severe nation of anxiety. When a customer is in a intense or panic country
of hysteria, it's miles important for the nurse to remain with the purchaser. The customer in a
extreme nation of tension would be unable to learn relaxation strategies. Discussing the attack
at this point would increase the purchaser's level of tension further. Placing the consumer in a
quiet room alone may additionally growth the tension stage.
A client diagnosed with delirium will become disoriented and burdened at night time. Which
intervention should the nurse put into effect to begin with?
1. Move the patron subsequent to the nurse's station.
2. Use an indirect light supply and flip off the television.
3. Keep the television and a gentle mild on in the course of the night.
4. Play smooth track in the course of the night, and keep a nicely-lit room. - ANS-2. Use an
oblique mild supply and flip off the tv.
Rationale:
Provision of a regular daily ordinary and a low stimulating surroundings is vital when a customer
is disoriented. Noise, such as radio and tv, may additionally upload to the confusion and
disorientation. Moving the purchaser subsequent to the nurses' station may also end up
important but isn't the initial movement.
A client diagnosed with terminal cancer says to the nurse, "I'm going to die, and I want my own
family could forestall hoping for a remedy! I get so irritated while they bring on like this. After all,
I'm the one who is loss of life." Which reaction by means of the nurse is therapeutic?
1. "Have you shared your emotions with your family?"
2. "I suppose we ought to communicate more about your anger together with your family."
3. "You're feeling indignant that your family keeps to pray a good way to be cured?"
4. "You are probable very depressed, that is understandable with the sort of diagnosis." -
ANS-3. "You're feeling indignant that your family keeps to pray if you want to be cured?"
Rationale:
Restating is a therapeutic communication method wherein the nurse repeats what the client
says to expose expertise and to check what was said. While it's far suitable for the nurse to
attempt to assess the patron's capacity to speak about feelings brazenly with circle of relatives
members, it does no longer help the purchaser speak the feelings causing the anger. The
nurse's try and cognizance at the critical problem of anger is premature. The nurse might by no
means make a judgment regarding the purpose for the client's feeling; this is nontherapeutic in
the one-to-one courting.
A consumer experiencing a excellent deal of stress and anxiety is being taught to apply strength
of mind therapy. Which announcement by way of the consumer suggests a need for further
teaching approximately the remedy?
,1. "This shape of therapy can be carried out to new situations."
2. "An benefit of this method is that change is possibly to remaining."
3. "Talking to oneself is a fundamental aspect of this shape of therapy."
4. "This shape of remedy gives a terrible reinforcement while the stimulus is produced." -
ANS-four. "This shape of therapy presents a bad reinforcement while the stimulus is produced."
Rationale:
Negative reinforcement when the stimulus is produced is descriptive of aversion therapy.
Options 1, 2, and three are traits of strength of mind remedy.
A client experiencing disturbed thought techniques believes that his food is being poisoned.
Which communication approach need to the nurse use to inspire the consumer to eat?
1. Using open-ended questions and silence
2. Sharing non-public desire concerning food picks
3. Documenting reasons why the purchaser does no longer need to eat
4. Offering opinions about the necessity of ok nutrients - ANS-1. Using open-ended questions
and silence
Rationale:
Open-ended questions and silence are techniques used to encourage customers to discuss
their troubles. Sharing private food choices isn't always a client-centered intervention. The final
options are not helpful to the customer due to the fact they do no longer encourage the
purchaser to express emotions. The nurse need to not offer reviews and must inspire the
purchaser to become aware of the motives for the behavior.
A customer has been recognized with most important depression. The nurse notes that the
consumer isn't eating correctly and at times refuses to devour. What ought to the nurse plan to
do to fulfill the patron's nutritional wishes?
1. Force meals and fluids.
2. Provide small, frequent food.
Three. Provide snacks and food as requested.
Four. Tell the consumer that social activities may be constrained except meals intake is
extended. - ANS-2. Provide small, frequent meals.
Rationale:
A depressed customer may additionally devour small amounts of food due to the fact big
amounts may additionally seem overwhelming. If the purchaser will become overwhelmed, he or
she might also reply by means of retreating further. Providing snacks and food whilst the
consumer requests them will not ensure ok dietary consumption. Forcing foods and fluids and
telling the consumer that social sports will be limited will cause further withdrawal by the
customer. Telling the consumer that social sports could be restricted is also a demeaning action.
A purchaser has been prescribed disulfiram (Antabuse). Before giving the patron the primary
dose of this medicine, what need to the psychiatric home fitness nurse determine?
, 1. If there's a history of hyperthyroidism
2. When the last full meal changed into fed on
three. If there may be a history of diabetes insipidus
four. When the last alcoholic drink became consumed - ANS-4. When the last alcoholic drink
changed into fed on
Rationale:
Disulfiram is an adjunctive remedy for some clients with continual alcoholism to help in keeping
enforced sobriety. Because customers ought to abstain from alcohol for at the least 12 hours
earlier than the initial dose, the maximum vital assessment is whilst the closing alcoholic intake
become fed on. The medication ought to be used cautiously in clients with hypothyroidism,
diabetes mellitus, epilepsy, cerebral harm, nephritis, and hepatic disorder. It is contraindicated in
humans with extreme coronary heart disease, psychosis, or allergic reaction to the medicine.
A consumer is admitted to a medical nursing unit with a analysis of acute blindness after being
involved in a hit-and-run coincidence. When diagnostic trying out can not become aware of any
natural cause why this client can't see, a intellectual fitness seek advice from is prescribed.
Which circumstance can be the focus of this consult?
1. Psychosis
2. Repression
three. Conversion disorder
4. Dissociative sickness - ANS-three. Conversion disease
Rationale:
A conversion sickness is the alteration or lack of a bodily characteristic that can't be explained
by using any known pathophysiological mechanism. A conversion disease is concept to be an
expression of a mental need or warfare. In this situation, the consumer witnessed an
coincidence that became so psychologically painful that the patron have become blind.
Psychosis is a kingdom wherein someone's mental capability to apprehend truth, speak, and
relate to others is impaired, interfering with the man or woman's ability to cope with life's needs.
Repression is a coping mechanism in which unacceptable feelings are saved out of focus. A
dissociative ailment is a disturbance or alteration within the generally integrative features of
identification, memory, or cognizance.
A purchaser is admitted to the intellectual fitness unit after an tried suicide by way of placing.
The nurse can high-quality make certain purchaser protection by means of which movement?
1. Requesting that a peer continue to be with the patron always
2. Removing the patron's garb and placing the client in a medical institution robe
three. Assigning a group of workers member to the patron who will continue to be with the client
always
4. Admitting the patron to a seclusion room where all potentially dangerous articles are
eliminated - ANS-3. Assigning a team of workers member to the client who will stay with the
customer always
A purchaser admitted to a mental health unit for remedy of psychotic behavior spends hours on
the locked exit door shouting, "Let me out. There's not anything incorrect with me. I don't belong
right here." What defense mechanism is the consumer imposing?
1. Denial
2. Projection
3. Regression
four. Rationalization - ANS-1. Denial
Rationale:
Denial is refusal to confess to a painful truth, that's handled as if it does not exist. In projection,
a person unconsciously rejects emotionally unacceptable capabilities and attributes them to
different persons, gadgets, or conditions. Regression allows the purchaser to go back to an in
advance, greater comforting, despite the fact that much less mature, way of behaving.
Rationalization is justifying illogical or unreasonable ideas, actions, or feelings via growing
perfect causes that satisfy the teller and the listener.
A customer being seen in the emergency branch straight away after being sexually assaulted
seems calm and managed. The nurse analyzes this conduct as indicating which protection
mechanism?
1. Denial
2. Projection
three. Rationalization
four. Intellectualization - ANS-1. Denial
Rational:
Denial is refusal to admit to a painful truth and can be a reaction with the aid of a sufferer of
sexual abuse. In this situation the client isn't always acknowledging the trauma of the assault
either verbally or nonverbally. Projection is transferring one's inner feelings, thoughts, and
unacceptable ideas and tendencies to someone else. Rationalization is justifying the
unacceptable attributes about oneself. Intellectualization is the immoderate use of abstract
questioning or generalizations to decrease painful questioning.
A consumer involves the emergency department after an attack and is extraordinarily agitated,
trembling, and hyperventilating. What is the priority nursing action for this consumer?
1. Begin to teach relaxation strategies.
2. Encourage the purchaser to speak about the assault.
3. Remain with the purchaser till the tension decreases.
,4. Place the purchaser in a quiet room on my own to decrease stimulation. - ANS-three. Remain
with the purchaser till the anxiety decreases.
Rationale:
This customer is in a severe nation of anxiety. When a customer is in a intense or panic country
of hysteria, it's miles important for the nurse to remain with the purchaser. The customer in a
extreme nation of tension would be unable to learn relaxation strategies. Discussing the attack
at this point would increase the purchaser's level of tension further. Placing the consumer in a
quiet room alone may additionally growth the tension stage.
A client diagnosed with delirium will become disoriented and burdened at night time. Which
intervention should the nurse put into effect to begin with?
1. Move the patron subsequent to the nurse's station.
2. Use an indirect light supply and flip off the television.
3. Keep the television and a gentle mild on in the course of the night.
4. Play smooth track in the course of the night, and keep a nicely-lit room. - ANS-2. Use an
oblique mild supply and flip off the tv.
Rationale:
Provision of a regular daily ordinary and a low stimulating surroundings is vital when a customer
is disoriented. Noise, such as radio and tv, may additionally upload to the confusion and
disorientation. Moving the purchaser subsequent to the nurses' station may also end up
important but isn't the initial movement.
A client diagnosed with terminal cancer says to the nurse, "I'm going to die, and I want my own
family could forestall hoping for a remedy! I get so irritated while they bring on like this. After all,
I'm the one who is loss of life." Which reaction by means of the nurse is therapeutic?
1. "Have you shared your emotions with your family?"
2. "I suppose we ought to communicate more about your anger together with your family."
3. "You're feeling indignant that your family keeps to pray a good way to be cured?"
4. "You are probable very depressed, that is understandable with the sort of diagnosis." -
ANS-3. "You're feeling indignant that your family keeps to pray if you want to be cured?"
Rationale:
Restating is a therapeutic communication method wherein the nurse repeats what the client
says to expose expertise and to check what was said. While it's far suitable for the nurse to
attempt to assess the patron's capacity to speak about feelings brazenly with circle of relatives
members, it does no longer help the purchaser speak the feelings causing the anger. The
nurse's try and cognizance at the critical problem of anger is premature. The nurse might by no
means make a judgment regarding the purpose for the client's feeling; this is nontherapeutic in
the one-to-one courting.
A consumer experiencing a excellent deal of stress and anxiety is being taught to apply strength
of mind therapy. Which announcement by way of the consumer suggests a need for further
teaching approximately the remedy?
,1. "This shape of therapy can be carried out to new situations."
2. "An benefit of this method is that change is possibly to remaining."
3. "Talking to oneself is a fundamental aspect of this shape of therapy."
4. "This shape of remedy gives a terrible reinforcement while the stimulus is produced." -
ANS-four. "This shape of therapy presents a bad reinforcement while the stimulus is produced."
Rationale:
Negative reinforcement when the stimulus is produced is descriptive of aversion therapy.
Options 1, 2, and three are traits of strength of mind remedy.
A client experiencing disturbed thought techniques believes that his food is being poisoned.
Which communication approach need to the nurse use to inspire the consumer to eat?
1. Using open-ended questions and silence
2. Sharing non-public desire concerning food picks
3. Documenting reasons why the purchaser does no longer need to eat
4. Offering opinions about the necessity of ok nutrients - ANS-1. Using open-ended questions
and silence
Rationale:
Open-ended questions and silence are techniques used to encourage customers to discuss
their troubles. Sharing private food choices isn't always a client-centered intervention. The final
options are not helpful to the customer due to the fact they do no longer encourage the
purchaser to express emotions. The nurse need to not offer reviews and must inspire the
purchaser to become aware of the motives for the behavior.
A customer has been recognized with most important depression. The nurse notes that the
consumer isn't eating correctly and at times refuses to devour. What ought to the nurse plan to
do to fulfill the patron's nutritional wishes?
1. Force meals and fluids.
2. Provide small, frequent food.
Three. Provide snacks and food as requested.
Four. Tell the consumer that social activities may be constrained except meals intake is
extended. - ANS-2. Provide small, frequent meals.
Rationale:
A depressed customer may additionally devour small amounts of food due to the fact big
amounts may additionally seem overwhelming. If the purchaser will become overwhelmed, he or
she might also reply by means of retreating further. Providing snacks and food whilst the
consumer requests them will not ensure ok dietary consumption. Forcing foods and fluids and
telling the consumer that social sports will be limited will cause further withdrawal by the
customer. Telling the consumer that social sports could be restricted is also a demeaning action.
A purchaser has been prescribed disulfiram (Antabuse). Before giving the patron the primary
dose of this medicine, what need to the psychiatric home fitness nurse determine?
, 1. If there's a history of hyperthyroidism
2. When the last full meal changed into fed on
three. If there may be a history of diabetes insipidus
four. When the last alcoholic drink became consumed - ANS-4. When the last alcoholic drink
changed into fed on
Rationale:
Disulfiram is an adjunctive remedy for some clients with continual alcoholism to help in keeping
enforced sobriety. Because customers ought to abstain from alcohol for at the least 12 hours
earlier than the initial dose, the maximum vital assessment is whilst the closing alcoholic intake
become fed on. The medication ought to be used cautiously in clients with hypothyroidism,
diabetes mellitus, epilepsy, cerebral harm, nephritis, and hepatic disorder. It is contraindicated in
humans with extreme coronary heart disease, psychosis, or allergic reaction to the medicine.
A consumer is admitted to a medical nursing unit with a analysis of acute blindness after being
involved in a hit-and-run coincidence. When diagnostic trying out can not become aware of any
natural cause why this client can't see, a intellectual fitness seek advice from is prescribed.
Which circumstance can be the focus of this consult?
1. Psychosis
2. Repression
three. Conversion disorder
4. Dissociative sickness - ANS-three. Conversion disease
Rationale:
A conversion sickness is the alteration or lack of a bodily characteristic that can't be explained
by using any known pathophysiological mechanism. A conversion disease is concept to be an
expression of a mental need or warfare. In this situation, the consumer witnessed an
coincidence that became so psychologically painful that the patron have become blind.
Psychosis is a kingdom wherein someone's mental capability to apprehend truth, speak, and
relate to others is impaired, interfering with the man or woman's ability to cope with life's needs.
Repression is a coping mechanism in which unacceptable feelings are saved out of focus. A
dissociative ailment is a disturbance or alteration within the generally integrative features of
identification, memory, or cognizance.
A purchaser is admitted to the intellectual fitness unit after an tried suicide by way of placing.
The nurse can high-quality make certain purchaser protection by means of which movement?
1. Requesting that a peer continue to be with the patron always
2. Removing the patron's garb and placing the client in a medical institution robe
three. Assigning a group of workers member to the patron who will continue to be with the client
always
4. Admitting the patron to a seclusion room where all potentially dangerous articles are
eliminated - ANS-3. Assigning a team of workers member to the client who will stay with the
customer always
