MENTAL HESI V1- V7 2021

MENTAL HESI V1 2021 1-A 6-year-old girl with severe birth defects who is mentally disabled is brought to the emergency room because of a broken arm. The caregiver reports that the girl sustained the injury when she fell from her wheelchair. Which intervention is most important for the nurse to implement? Evaluate the child for other injuries. Rationale: Because a 6-year-old child with low level fall that results in a fracture should be considered a possible victim of child abuse, until proven otherwise. 2-The community health nurse facilitates a substance abuse prevention group for a homeless population. Which statement demonstrates that a client has a realistic understanding of the recovery process? "By learning what led to my latest relapse, I know what to do in the future." Rationale: Recovery is a lifelong process in which clients must constantly learn and apply new behaviors to replace ineffective ones. Every attempt toward recovery improves long-term chances of success, so those who learn from their relapses demonstrate an understanding of the process. 3-A woman admitted to the Emergency Department is bleeding profusely from a patch where her hair was lost from her scalp. She is accompanying by her husband who tells the nurse that his wife caught her hair on the railing and pulled it out when she fell down the stairs. The husband is solicitous of his wife and quickly answers questions on her behalf. He attempts to comfort his wife by saying to her, "I am right here with you, dear. Nothing can keep us apart." What is the priority nursing intervention? Require the husband to leave the cubicle while the client is being treated. Rationale: This client should be questioned about the possibility of spousal abuse and cannot answer truthfully in the presence of the perpetrator, so separating the couple is a priority. 4-While assessing a 70-year old male client, a nurse working in the outpatient clinic notices bruises on the client's chest. The client admits that his daughter, who is his caregiver, becomes frustrated and sometimes hits him. What is the priority outcome for the elderly client who sustained the abuse? Expresses his feelings of satisfaction with care. Rationale: Abuse cessation should result in the client feeling satisfied with his care.