Hesi Mental health Exam Questions And Answers

Hesi Mental health Exam Questions And Answers A mental health technician arrives to help the client take a shower. The technician gathers towels and shower items, then helps the client to the shower. When entering the shower, the client slips and falls to the floor. The technician reports the incident to the nurse. The nurse assesses the client who denies suffering any injuries. The nurse documents the assessment, which includes a full set of vital signs, and then notifies the healthcare provider (HCP). The nurse knows an adverse event report must be completed. Who should the nurse ask to complete the adverse event report? - ANSWER-The technician helping at the time of the accident needs to complete the report. Rationale: The nurse should ask the technician to complete the report because the technician witnessed the client's fall. .A simple tool the nurse can use to screen for alcoholism is the CAGE questionnaire. CAGE is an acronym that represents the four questions it contains. What is the first question that the nurse should ask? - ANSWER-"Have you ever thought that you should cut down on your drinking?" Rationale: This is the first question in the questionnaire. In CAGE, C stands for cut down. Alcoholic may realize they consume too much alcohol, which leads to uninhibited and embarrassing behavior. When sober, an alcoholic may make a pledge to reduce consumption. .According to the nursing progress notes, the client demonstrates decreased social interaction, she rarely talks, she needs assistance to her room and appears confused. The client only slept 30 minutes in the past 24 hours, and the daily graphics indicate that she has slept an average of 2 hours in the past week. She is eating 50% of her meals. According to this data, what is the priority nursing problem? - ANSWER-Sleep disturbance. Rationale: Considering Maslow's hierarchy, physiologic needs should be addressed first, so this is the priority problem because the client is receiving inadequate sleep. Eating 50% of her meals is acceptable, provided that the client is not losing weight. .After 3 days in the crisis stabilization unit, the client exhibits no further withdrawal symptoms. The nurse collaborates with the social worker and the HCP to determine discharge plans. The client wants to return to work as soon as possible. The client describes work as being a trigger for drinking and asks the nurse what can be done to prevent a relapse. Which response by the nurse is accurate? - ANSWER-Disulfiram inhibits absorption of alcohol. Rationale: Disulfiram inhibits the absorption of alcohol and raises the level of acetaldehyde, causing a severe reaction when alcohol is ingested. .After 9 days of hospitalization, the client demonstrates fewer hallucinations, and his thoughts are not influenced by delusions. The client explains that several months before admission, he and his HCP decided that he could stop taking his psychotropic medications. He states that he does not know what happened and stated that he thought that he was handling everything just fine. The client's discharge is planned within several days. Medication prescriptions for discharge include olanzapine 5 mg PO daily BID. The nurse plans to educate the client about side effects that do not go away. What are important reasons for this teaching? (Select all that apply. One, some, or all options may be correct.) - ANSWER-To encourage the client to continue compliance with medications. Rationale: Education about side effects is important so that medication compliance can be enhanced. To monitor for early tardive dyskinesia, which can be reversible. Rationale: It is very important to teach the client to report uncontrollable movements of the face or extremities so that the nurse can assess for tardive dyskinesia and suggest modifications in the client's medication regimen. Tardive dyskinesia, although rare with olanzapine, can be reversed, by reducing the medication dose, if it is assessed in a timely manner. To reinforce education done throughout the hospitalization. Rationale: Educating the client about medications at discharge will reinforce the client's knowledge To tell the cliet to discuss symptoms with his nurse. Rationale: It is very important to reinforce the client's medication compliance by recommending that the client discuss any uncontrollable movements of the face or extremities so that the nurse can assess for tardive dyskinesia. .After several days of constant observation, the nurse reassesses the need to maintain safety precautions. What is the best predictor of client safety? - ANSWER-The client agrees to talk with staff if she has thoughts of self-harm. Rationale: If the client agrees to talk with staff if thoughts of self-harm occur, constant observation for safety can be changed. Risk for self-harm should continue to be assessed every shift. .After several days of taking an MAO Inhibitor, the client refuses to continue taking the medication, and the medication is discontinued. Which specific nursing consideration is most important? - ANSWER-Maintain a low-tyramine or tyramine-free diet for 10 to 14 days. Rationale: The client should minimize or avoid substances with tyramine for 10 to 14 days after discontinuation of the medication due to the medication still in the client's system. .After the content of the voices are assessed, which interventions should the nurse implement? (Select all that apply. One, some, or all options may be correct.) - ANSWER-Ask the client how the voices make them feel. Rationale: It may be helpful to know how the voices make the client feel. It can provide understanding to the client's actions and reactions so they can be addressed in a therapeutic manner. Instruct the client to utilize distractions to deal with hallucinations. Rationale: Once the hallucinations have been revealed and evaluated, it is important to disconnect the hallucinations from reality. Distractions can be a therapeutic. .As part of the admission process, the nurse orients the client to the program and to his room. What is the most important part of this admission process? - ANSWER-Take away the client's cigarettes and lighter. Rationale: Safety for the client and the unit environment is the highest priority, so the staff should keep any potentially dangerous objects away from the client. .As the client is leaving the unit, the caseworker remembers that some of the client's medication bottles were brought to the hospital and the caseworker wants to return them to the client. Which nursing action is appropriate for this request? - ANSWER-Obtain a prescription from the HCP to return medications. Rationale: The HCP must write a prescription for the client to receive medications. Medications were changed while hospitalized and required prescriptions should accompany the client upon discharge. All other medication should be properly disposed of as prescribed. .As the nurse initially communicates with the client, which communication technique is important? - ANSWER-Acknowledge the client's courage in seeking help, then offer to sit quietly with the client. Rationale: Offering nonjudgmental acceptance and companionship will help develop trust. Acknowledging the step the client took in seeking help may restore the client's sense of control over her situation. .Because the client has hallucinations and delusions, the nurse develops an initial plan of care related to psychosis.