2019 HESI RN MENTAL HEALTH 53 Q & A Graded A

1. When caring for an older client, the nurse observes multiple bruises in over the client’s legs, arms, back, and gluteal areas. When the client contacts, the nurse suspects elder abuse. What action should the nurse? □ Measure and document size, shape and color of the bruised areas. 2. A client who is homeless is diagnosed with schizophrenia and admitted on an involuntary basis to e mental health hospital 4 days ago. The client stopped taking prescribed antipsychotic drugs approximately one month ago. Since hospitalization the client continues to have poor judgment and refuses all medications. What action should the nurse take? □ Administer a long acting antipsychotic medication so that the client can be discharged to a shelter. 3. After receiving treatment for anorexia, a student asks the school nurse for permission to work in the school cafeteria as part of the school’ mpro/hgreamsi. What action should the nurse take? Recommend assignment to the receptionist’s office. 4. A male client comes to the emergency center because he has an erection that will not resolve. The client reports that he is taking trazodone (Desyrel for insomnia. Which information is most important for the nurse to ask this client? □ Have you taken any medication for erectile dysfunction? 5. On admission to the mental health unit, a client diagnosed with schizophrenia tells the nurse that he is the son of God. Based on this statement, which intervention should thenurse include in this client’s plan of care? □ Confront his delusion as not consistent with reality. 6. The nurse on the day shift receives report about a client with depression who wasin bed most of the weekend. The nurse walks into the client’s room in the morning and finds the client in bed. What intervention I best for the nurse to implement? □ Assist the client to get out of bed and involved in an activity. 7. Which client information indicates the need for the n ur seto use the CAGE questionnaire during the admission interview? □ Describes self as a social drinker who drinks alcoholic beverages daily. 8. A female client admitted to the mental health unit stats to shout and scream atthe nurse. What is he best approach for the nurse to take? □ Stay quietly with the client. 9. A woman is brought to the psychiatric clinic by her husband. He reports that his wife is reluctant to leave home because of what she describes as a fear of open places and crows. Which nursing problems applies to the client’s behavior? □ Anxiety related to real or perceived threat to physical integrity. 10. A client is receiving benztropine mesylate (Cogentin) for drug-induced extrapyramidal syndrome (EPS). Which finding indicates that the RN should further evaluate the client? □ Presence of a dry mouth. 11. A male client in the mental health unit is guarded and vaguely answers the nurse’s questions. He isolates in his room and sometimes opens the door to peek into the hall. Which problem can the RN anticipate? □ Delusions of persecution.