MENTAL HESI 5 (50 Questions) (Latest Update) (A Graded) Latest Questions and Complete Solutions

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MENTAL HESI 5 (50 Questions) (Latest Update) (A Graded) Latest Questions and Complete Solutions 1. A 25-year-old female client has been particularly restless and the nurse finds her trying to leave t... he psychiatric unit. She tells the nurse, "Please let me go. I must leave because the secret police are after me." What response is best for the nurse to make? a. "No one is after you, you're safe here." b. "You'll feel better after you have rested." c. "I know you must feel lonely and frightened." d. "Come with me to your room and I will sit with you." (D) is the best response because it offers support without judgment or demands. (A) is challenging the client's delusion. (B) is offering false reassurance. (C) is a violation of therapeutic communication in that the nurse is telling the client how she feels (frightened and lonely), rather than allowing the client to describe her own feelings. Hallucinating and/or delusional clients are not capable of discussing their feelings, particularly when they perceive a crisis. 2. A client who is being treated with lithium carbonate for manic depression begins to develop diarrhea, vomiting, and drowsiness. What action should the nurse take? a. Notify the physician immediately and force fluids. b. Prior to giving the next dose, notify the physician of the symptoms. c. Record the symptoms and continue medication as prescribed. d. Hold the medication and refuse to administer additional amounts of the drug. Early side effects of lithium carbonate (occurring with serum lithium levels below 2.0 mEq per liter) generally follow a progressive pattern beginning with diarrhea, vomiting, drowsiness, and muscular weakness (B). At higher levels, ataxia, tinnitus, blurred vision, and large dilute urine output may occur. Forcing fluids (A) will lower the lithium level. Although these are expected symptoms, the physician should be notified prior to the next administration of the drug (C). Refusing to administer the medication (D) is not warranted. 3. A male schizophrenic client, taking fluphenazine deconate (Prolixin deconate), is being discharged in the morning. A repeat dose of medication is scheduled for 20 days after discharge. The client tells the nurse that he is going on vacation and will return in 18 days. Which statement by the client indicates a need for health teaching? a. "I am going to have lots of time in the sun." b. "While I am on vacation, I will not eat or drink anything that contains alcohol." c. "I will notify the doctor if I have a sore throat or flu-like symptoms." d. "I will continue to take my benzotropine mesylate (Congentin) every day." Photosensitivity is a side effect of Prolixin, therefore the client should be instructed to avoid the sun (A). (B, C, and D) indicate accurate knowledge. Alcohol acts synergistically with Prolixin (B). A sore throat and flu-like symptoms (C) are signs of agranulocytosis which is also a side effect of Prolixin. To avoid extrapyramidal symptoms (EPS), anticholinergic drugs, such as Cogentin (D), are often prescribed prophylactically with Prolixin. 4. An adult client with a medical diagnosis of substance abuse and schizophrenia was recently switched from oral fluphenazine HCl (Prolixin) to IM fluphenazine decanoate (Prolixin Decanoate) because of medication noncompliance. What is important to teach the client and family about this change in medication regimen? a. Long-acting medication is more effective than daily medication. b. A client with substance abuse must not take any oral medications. c. There will continue to be a risk of alcohol and drug interaction. d. Support groups are only helpful for substance abuse treatment. Alcohol enhances the side effects of Prolixin. The half-life of Prolixin po is 8 hours, whereas the half-life of the Prolixin Decanoate IM is 2 to 4 weeks. Therefore, the side effects of drinking alcohol are far more severe when the client drinks alcohol after taking the long acting Prolixin Decanoate IM. (A, B, and D) provide incorrect information. 5. The nurse develops a plan of care for a client with symptoms of paranoia and psychosis. The priority nursing diagnosis is "Impaired social interactions related to inability to trust." Which intervention is most important for the nurse to implement? a. Greet the client by first name during each social interaction. b. Determine if the client is experiencing auditory hallucinations. c. Introduce the client to peers on the unit as soon as possible. d. Assign the client to a group about developing social skills. The most important nursing intervention is to greet the client by name (A) and provide short, frequent contact to establish trust. The presence of auditory hallucinations can impact social interactions (B), but it is not a priority intervention. Introducing the client to peers (C) and assigning the client to a group about social skills (D) are effective interventions after individual rapport has been established with the client. [Show More]

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