MENTAL HESI 5

MENTAL HESI 5 1. A male client is admitted to the mental health unit because he was feeling depressed about the loss of his wife and job. The client has a history of alcohol dependency and admits that he was drinking alcohol 12 hours ago. His temperature is 100.0 F, pulse is 100, and blood pressure is 142/100. The nurse plans to give the client lorazepam (Ativan) based on which priority nursing diagnosis? a. Risk for injury related to suicidal ideation. b. Risk for injury related to alcohol detoxification. c. Knowledge deficit related to ineffective coping. d. Health seeking behaviors related to personal crisis. The most important nursing diagnosis is related to alcohol detoxification (B) because the client has elevated vital signs, a sign of alcohol detoxification. Maintaining client safety related to suicidal ideation (A) should be addressed after giving the client Ativan for elevated vital signs secondary to alcohol withdrawal. The client's knowledge deficit and health seeking behaviors (C and D) can be addressed when immediate needs for safety are met. 2. A nurse working in the emergency room of a children's hospital admits a child whose injuries could have resulted from abuse. Which statement most accurately describes the nurse's responsibility in cases of suspected child abuse? a. Obtain objective data such as x-rays before reporting suspicions. b. Confirm suspicions of abuse with the physician. c. Report any case of suspected child abuse. d. Document injuries to confirm suspected abuse. It is the nurse's legal responsibility to report all suspected cases of child abuse (C), and notifying the nurse manager or charge nurse starts the legal reporting process. (A, B, and D) delay the first step in reporting the abuse. 3. A child is brought to the emergency room with a broken arm. Because of other injuries, the nurse suspects the child may be a victim of abuse. When the nurse tries to