HESI MENTAL HEALTH(100% ACCURATE
SOLUTIONS) GRADED A+| 2025 LATEST
UPDATED | COMPLETE QUESTIONS WITH
CORRECT ANSWERS| GET IT CORRECT!!
After removing the sheet, what is the next nursing action? - ANSWER -
Remain with the client.
Rationale: The nurse should begin constant observation immediately for
safety precautions because the client is at risk for self-harm. The other
,interventions are important, but it is most important for a staff member
to remain with the client.
The nurse stays with the client until another staff member arrives and
safety precautions are initiated. A staff member must keep the client
within eye sight at all times and document her activity every 15
minutes.
When the client wants to change clothes and get ready for sleep at
night, what should the staff do? - ANSWER - Stay with the client while
she gets ready.
Rationale: This approach respects the client's privacy and also ensures
she stays safe.
The client is placed on constant observation for safety precautions, so
the nurse must assign a staff member to remain with her at all times.
Which staff member is best to assign to the client? - ANSWER - Female
unlicensed assistive personnel.
Rationale: An unlicensed staff member can assume responsibility for
the client's safety and maintain documentation. A female staff member
is less threatening than a male staff member when the client desires as
much privacy as possible.
,While the client is on constant observation, the nurse must assure that
safety is maintained in the milieu. One afternoon, the nurse notices that
a visitor brings some cans of the client's favorite soft drink.
After ensuring the client is not on caffeine or sugar restrictions, what
should the nurse do? - ANSWER - Pour the soft drink into a paper cup.
Rationale: The nurse should pour the drink in a paper cup, because the
client could use the can to hurt herself.
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.
The nurse must teach the client about possible adverse effects from the
ECT treatments. Which information should be included in the teaching
plan? - ANSWER - Headache, nausea, and muscle aches may occur
after the treatment.
Rationale: Headache, nausea, and muscle aches are common side
effects. Confusion and disorientation are short-term.
, When the nurse prepares the client for ECT, what should be expected? -
ANSWER - Preparation is similar to a brief surgical procedure.
Rationale: Preparation for ECT is similar to a surgical procedure. For
example, the client must remain NPO for 6 to 8 hours prior to treatment
with the exception of receiving cardiac medications or antihypertensive
agents. Prostheses should be removed, and the client should void
immediately before receiving ECT.
When the client awakens from the treatment, the nurse should be
prepared to perform which nursing action? - ANSWER - Take vital signs
and assess orientation.
Rationale: The nurse should monitor orientation and vital signs until
they return to an acceptable level or for a specified time according to
hospital protocol.
What signs and symptoms should the nurse expect to assess if a client
taking an MAO antidepressant ingests foods containing tyramine? -
ANSWER - Headache and palpitations.
Rationale: Explosive headache, palpitations, sudden elevation of blood
pressure, chest pain, nausea, and vomiting are some of the symptoms
of a hypertensive crisis related to tyramine consumption.
The nurse plans to give the client a list of safe and unsafe foods that
contain tyramine. Unsafe foods have high tyramine content, and safe
foods have little or no tyramine.
SOLUTIONS) GRADED A+| 2025 LATEST
UPDATED | COMPLETE QUESTIONS WITH
CORRECT ANSWERS| GET IT CORRECT!!
After removing the sheet, what is the next nursing action? - ANSWER -
Remain with the client.
Rationale: The nurse should begin constant observation immediately for
safety precautions because the client is at risk for self-harm. The other
,interventions are important, but it is most important for a staff member
to remain with the client.
The nurse stays with the client until another staff member arrives and
safety precautions are initiated. A staff member must keep the client
within eye sight at all times and document her activity every 15
minutes.
When the client wants to change clothes and get ready for sleep at
night, what should the staff do? - ANSWER - Stay with the client while
she gets ready.
Rationale: This approach respects the client's privacy and also ensures
she stays safe.
The client is placed on constant observation for safety precautions, so
the nurse must assign a staff member to remain with her at all times.
Which staff member is best to assign to the client? - ANSWER - Female
unlicensed assistive personnel.
Rationale: An unlicensed staff member can assume responsibility for
the client's safety and maintain documentation. A female staff member
is less threatening than a male staff member when the client desires as
much privacy as possible.
,While the client is on constant observation, the nurse must assure that
safety is maintained in the milieu. One afternoon, the nurse notices that
a visitor brings some cans of the client's favorite soft drink.
After ensuring the client is not on caffeine or sugar restrictions, what
should the nurse do? - ANSWER - Pour the soft drink into a paper cup.
Rationale: The nurse should pour the drink in a paper cup, because the
client could use the can to hurt herself.
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.
The nurse must teach the client about possible adverse effects from the
ECT treatments. Which information should be included in the teaching
plan? - ANSWER - Headache, nausea, and muscle aches may occur
after the treatment.
Rationale: Headache, nausea, and muscle aches are common side
effects. Confusion and disorientation are short-term.
, When the nurse prepares the client for ECT, what should be expected? -
ANSWER - Preparation is similar to a brief surgical procedure.
Rationale: Preparation for ECT is similar to a surgical procedure. For
example, the client must remain NPO for 6 to 8 hours prior to treatment
with the exception of receiving cardiac medications or antihypertensive
agents. Prostheses should be removed, and the client should void
immediately before receiving ECT.
When the client awakens from the treatment, the nurse should be
prepared to perform which nursing action? - ANSWER - Take vital signs
and assess orientation.
Rationale: The nurse should monitor orientation and vital signs until
they return to an acceptable level or for a specified time according to
hospital protocol.
What signs and symptoms should the nurse expect to assess if a client
taking an MAO antidepressant ingests foods containing tyramine? -
ANSWER - Headache and palpitations.
Rationale: Explosive headache, palpitations, sudden elevation of blood
pressure, chest pain, nausea, and vomiting are some of the symptoms
of a hypertensive crisis related to tyramine consumption.
The nurse plans to give the client a list of safe and unsafe foods that
contain tyramine. Unsafe foods have high tyramine content, and safe
foods have little or no tyramine.
