MEDSURGE HESSI 2018 1.

MENTAL HESI 3 1. Which technique is the most important therapeutic tool a nurse should use to provide quality care to a psychiatric client? A. Context. B. Self-analysis. Correct C. Counter transference. D. Therapeutic self-disclosure. Self-analysis is a tool for the nurse to examine oneself, view one's responses in various mental and emotional moments, and provide a sense of how sensitive care should be provided relative to one's own needs, so (B) is a primary tool used by the nurse to establish therapeutic empathy and achieve authentic, open, and personal communication with a client. Although (A, C, and D) may occur in a nurse-client relationship, they may not contribute to establishing a therapeutic relationship. 2. The nurse completes an emergency admission of a male client with schizophrenia who has not been taking his antipsychotic medications. The client is pacing, is extremely irritable, and has a blood pressure of 146/96. What is the priority nursing action? A. Encourage the client to stop pacing and sit down. B. Reevaluate the client's blood pressure in an hour. Correct C. Direct the client to attend recreational therapy. D. Review the client's baseline blood pressure. The client is irritable and pacing, which can contribute to the elevated BP, so reevaluation of the client's BP in an hour (B) allows time for the excitement and stress of the admission process to abate. (A) is likely to increase the client's agitated state. Recreational therapy (C) provides another environmental stimulus, which can contribute to the client's anxiety. (D) is helpful, but the most immediate action is to retake the blood pressure in one hour. 3. A young adult female client with panic disorder arrives in the Emergency Center with a 4- day history of chest pain that began when her boyfriend left her. Initial assessment reveals normal cardiopulmonary findings. Which information is most important for the nurse to obtain? A. Drugs taken in last 7 days. Correct B. Family history of suicide. C. Usual coping mechanisms. D. Frequency of anxiety attacks. Use of prescribed, over-the-counter, and illicit drugs (A) is the most important information to obtain when planning care because drugs are likely to influence the client's behavior and ability to cope with stressful situations. (B, C, and D) are worthwhile assessment findings, but they do not have the priority of (A).