*NURSING > HESI > HESI Mental Health Practice Quiz 3/HESI Mental Health Practice Quiz 3. (All)

HESI Mental Health Practice Quiz 3/HESI Mental Health Practice Quiz 3.

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HESI Mental Health Practice Quiz 3/HESI Mental Health Practice Quiz 3. The nurse is caring for a female client who is admitted for depression with the nursing diagnosis, Self-esteem, chronic low. Whi... ch client response indicates to the nurse that the client has improved self-esteem? o Identifies own strengths. Correct o Asks the nurse if her behavior has improved. o Talks with other clients about marital advice. o Stops crying during every session. Identifying one's personal strengths (A) is an important part of increasing self-esteem. Crying during sessions with the nurse or other members of the healthcare team is a sign of depression or sadness, and (B) does not indicate an improved self-esteem. Talking with peers about marital advice (C) implies a lack of confidence in decision-making. Asking the nurse if one's behavior is improving (D) indicates a need for reassurance. Awarded 5.0 points out of 5.0 possible points. 2. 2.ID: 311194997 A male client on a psychiatric unit becomes extremely agitated and begins to smash his head against doors. He seems frightened, and his verbalizations suggest he is experiencing distorted sensory perceptions. What action should the nurse take first? o Administer a PRN dose of haloperidol (Haldol) IM. o Encourage the client to focus on his feelings of anger. o Place the client in mechanical restraints until calm. Correct o Use a calm, soothing voice to diffuse the situation. This client is demonstrating behaviors that may be a danger to himself or others, and in such an emergency situation, restraints may be applied by an authorized staff member (A). (B) may pose a danger to the staff. This client is experiencing distorted sensory perceptions, so he is unlikely to respond to (C) or have the ability to verbalize his feelings (D). Category: Psychiatric Mental Health Awarded 5.0 points out of 5.0 possible points. 3. 3.ID: 311192065 Which client should the nurse identify as the highest risk for the onset of stress-related problems? o A client who is passed over for promotion, quits a job to start a new business, and states, This is just one of a series of challenges I've faced in my life. o A person whose father died three months ago, who is losing a job due to company downsizing, and states, Living with loss and the threat of loss makes me feel helpless. Correct o A man whose new business is growing slowly, who plans to adopt a child with his wife, and says, I think I'm in control of my destiny. o A woman who is graduating from college, getting married in one month, and states, I'm anticipating the changes these events will make in my life. A client who is dealing with two stressful life events and expresses a cognitive appraisal of loss and helplessness (D) is at the highest risk for a stress-related health problem. (A, B, and C) describe persons who are coping with change using healthy strategies, such as perceiving change as challenging, expressing commitment to change, and believing they have control over their life paths. Awarded 5.0 points out of 5.0 possible points. 4. 4.ID: 311236320 The daughter of a 79-year-old male client tells the nurse that her father is becoming increasingly forgetful. Which finding indicates that the client needs further evaluation of cognitive function? o Cannot mentally retrace objects that were recently misplaced. Correct o Repeats the same stories to different family members or friends. o Cannot remember instructions to program an electronic device. o Forgets a planned event, then remembers the event a short while later. Inability to retrace misplaced objects (B) is an indicator of possible cognitive impairment that requires further assessment. (A, C, and D) are examples of benign forgetfulness. Awarded 5.0 points out of 5.0 possible points. 5. 5.ID: 311240030 The nurse is caring for an adult male client with catatonic schizophrenia who is mute and motionless. What is the priority nursing diagnosis? o Impaired mobility. Incorrect o Ineffective individual coping. o Impaired verbal communication. o High risk for fluid and electrolyte imbalance. Correct Maintaining physiological stability by first addressing basic physiological needs is the priority. A client who is in a catatonic or stuporous state is at risk for malnutrition and/or dehydration, so risk for fluid and electrolyte imbalance (D) is the priority nursing diagnosis for this client at this time. Lack of mobility (A) is related to psychomotor retardation rather than to physical limitations, and is not life-threatening. The client's mute state (C) and ineffective individual coping (B) can be addressed later in treatment. Awarded 0.0 points out of 5.0 possible points. 6. 6.ID: 311205630 An older client is admitted to a psychiatric hospital with the diagnosis, "Major depression, single episode." Which laboratory value is most important for the nurse to report to the healthcare provider immediately? o Increased serum creatinine level. o Elevated serum calcium level. o Positive rapid plasma reagin (RPR). o Increased thyroid stimulating hormone (TSH). Correct The healthcare provider should be notified of (C) immediately. An increased TSH suggests a low thyroxine level because the TSH is trying to stimulate thyroxine production, and hypothyroidism symptoms mimic those of depression. (A) often increases with aging. (B) is indicative of syphilis and should be reported, but does not have the priority of (C). (D) has implications for other illnesses, such as non-Hodgkin's lymphoma or hyperparathyroidism. Awarded 5.0 points out of 5.0 possible points. 7. 7.ID: 311243160 The nurse asks an older female client with cognitive impairment who has been hospitalized for three days how her previous evening was. The client replies, "I had the best time." My husband took me out to dinner and then to a concert. The music was wonderful. Which term should the nurse document to best describe the client's response? [Show More]

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