MENTAL HESI 4 (50 Questions) (A Graded) Latest Questions and Complete Solutions

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MENTAL HESI 4 1. A woman admitted to the Emergency Department is bleeding profusely from a patch where hair was lost from her scalp. She is accompanied by her husband who tells the nurse that his w... ife 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? A. Notify the local police of a suspected spousal abuse situation. B. Ask the hospital security to remove the husband from the treatment room. C. Reassure the husband that his wife will be treated well while he is in the waiting area. D. Require the husband to leave the cubicle while the client is being treated. Correct 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, and (D) is the best method of providing this separation. (A) is not the priority at this time, and permission to notify the police should be obtained from the client. (B) is premature. Abusive husbands are unlikely to respond to manipulation (C) and are also unlikely to leave based on reassurances alone. 2. 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? A. Verbalizes an acceptance of health status. B. Expresses his feelings of satisfaction with care. Correct C. States that the frequency of abuse has decreased. D. Describes the potential danger of his situation. Abuse cessation should result in the client feeling satisfied with his care (B). (A) is not identified as an issue. Total abuse cessation is the goal, not (C). (D) is of lesser importance than satisfaction with care. 3. The nurse is assessing a client who is believed to have a borderline personality disorder. Which question is most important to include in this assessment? A. At what age did you begin to exhibit symptoms? B. Do you have a family history of borderline disorder? C. How often do you drink alcoholic beverages? D. Do you frequently have temper tantrums? Correct Those with a borderline personality disorder demonstrate intense outbursts of anger, so (D) is the most important question to ask. (A, B, and C) provide worthwhile information, but do not have the priority of (D) when assessing a client who is suspected of having a borderline personality disorder. 4. A nurse is teaching a female client who is in a homosexual relationship about women's health. Which topic is the most important for the nurse to address? A. Sexually transmitted diseases. B. Annual gynecologic examination. C. Monthly breast self-examination. D. Domestic violence interventions. Correct Since all women, regardless of sexual orientation, are at risk for domestic violence that can be potentially lethal, this is the most important topic for the nurse to address (D). Although (A) can be transferred by skin contact or bodily fluids, they are not immediately life threatening. All women, including those involved in same sex relationships, should receive a screening gynecologic examination (B). Homosexual women have the same risk for breast cancer (C) as heterosexual women. 5. A client who abuses alcohol says to the nurse, I am glad I went in for treatment. Now my problems with alcohol are all behind me. Which response is best for the nurse to provide? A. Yes, the treatment program you attended has an excellent success profile. B. Can you tell me more about what you mean when you say that your problems with alcohol are now behind you? Correct C. You are likely to have a difficult time staying sober if you think that your problems with alcohol are behind you. D. Do you know what 'one day at a time' means for those who have problems with alcohol? Those who attend alcohol treatment programs and Alcoholics Anonymous never put drinking problems behind them and describe alcoholics as only one step away from a slip with maintaining sobriety. The nurse should use reflection and encourage the client to further describe the feelings (B). (A) avoids dealing with the client's misperception. (C) is threatening, and (D) could be interpreted as condescending. 6. A male client who is on the liver transplant list is called to the unit for a possible transplant. When learning that the donor organ is no longer available, the client slams doors and shouts vulgarities about his situation. What action should the nurse implement first? A. Encourage him to share his feelings more appropriately. B. Express concern over his disappointment. Correct C. Arrange to have a clergy person visit. D. Administer a PRN prescription for an antianxiety drug. Addressing the client's disappointment (B) enables the client to express feelings of frustration in a safe environment. (A) is dismissive, non-supportive, and could incite defensiveness. (C) may be indicated after other interventions are implemented. (D) should be a last resort because clients with liver failure have difficulty metabolizing medications. 7. A client is told that her infant will be stillborn. What is the most important action for the nurse to implement after the birth? A. Ask the family if they would like to see and hold the infant after birth. Correct B. Inquire if the parents want a picture taken after the infant is born. C. Discuss with the parents which funeral home should be notified. D. Find out if the client has a special outfit for the infant after the birth. Interventions and support from the nursing staff during a prenatal loss are extremely important in the grief process and healing of the parents. Research had shown it is most helpful for a mother and father to see and hold their deceased infant after delivery, so the parents should be given this opportunity initially after birth (A). (B, C, and D) should be done after determining the parents' wishes and providing the opportunity for bonding and closure with their infant. 8. A client who has a miscarriage at 10-weeks gestation tells the nurse that she already purchased some baby things and picked out a name. After the surgical dilation and curettage (D&C), the client wants to go home as soon as possible. Based on the client's statements, which action should the nurse implement? A. Ready the client for discharge. B. Notify pastoral care to offer the client a blessing. C. Ask the client what name she had picked out for the infant. Correct D. Inquire if the client would like to see what was obtained from her D&C. The client's cues about her preparation for the baby indicate her need to express her feelings of loss, so encouraging further discussion about the infant's name (C) provides an opportunity to offer support. (A) should be implemented upon direction of the healthcare provider. Although it may be therapeutic to offer religious support (B), the client should first be allowed to ventilate her feelings. (D) may be traumatic for the client. 9. Which nursing intervention should the nurse implement with parents who experience a fetal demise and express the wish not to see the baby? A. Tell them there is nothing to fear. B. Insist that they hold infant so they can grieve. C. Respect their wishes and release the body to the morgue. D. Keep the body available for a few hours in case they change their minds. Correct Grieving parents should be encouraged to hold their infant after death to facilitate closure. If parents are hesitant about seeing or holding their dead infant, the fetus should be available for a few hours (D) in the event they change their mind after the initial shock. (A) is non-supportive. (B) imposes the nurse's opinion and does not allow for individual expressions of grief. (C) does not provide a ready opportunity for the parents to hold the infant if they change their minds later. 10. A client actively involved in substance addiction therapy frequently relapses into benzodiazepines and alcohol use. The client tells the nurse, I don't think I will ever be able to kick this habit. How should the nurse respond? A. The goal of the individual is one of growth, health, autonomy, and self-actualization. B. All people have the right to an equal opportunity for adequate health care. C. Dependence on an extensive support system is needed to overcome any addiction. D. The client must participate in making decisions about his/her own physical and mental health. Correct The client has the right to self-determination and the responsibility to make a decision to pursue health or illness, so the client must actively participate (D). (A, B, and C) are components in addiction recovery, but do not indicate the client's responsibility and primary commitment for decision-making about his/her health. 11. A client who is admitted with the chief complaint of feeling depressed tells the nurse, I want to feel normal again. How should the nurse respond? A. How long have you felt this way? B. We are all here to help you get better. C. What do you think the hospital can do for you? D. Tell me more about how things are with you. Correct When a client offers psycho-emotional complaints as the reason for admission, open-ended statements that seek clarification and elaboration provide the nurse with information about the client's life experiences that helps the nurse empathize, establish rapport, and support the client while reexamining and expressing feelings. (A and C) are short answer responses that do not allow the client to vent. (B) dismisses the client's statement and is not therapeutic. 12. The nurse is planning the care for a client based on the psychoanalytical model. Which intervention should the nurse include? A. Emphasize the client's strengths and assets. B. Teach the importance of medication compliance. C. Offer the client psychoeducational materials to read. D. Focus on the client's positive or negative feelings toward the nurse. Correct Interactions and interventions that focus on the client's positive or negative feelings toward the nurse (D) are based on the psychoanalytical model of mental health care. (A, B, and C) are not interventions associated with the psychoanalytical model. 13. A female client responds to the nurse with negative comments and antagonistic behavior. The nurse tells the client that she is unconsciously casting the nurse in the role of the client's mother. The nurse's feedback is based on which model of therapy? A. Medical. B. Existential. C. Interpersonal. D. Psychoanalytical. Correct The psychoanalytical model (D) uses concepts that interpret and focus on working through previously unresolved conflicts. The medical model (A) focuses on the diagnosis of a mental illness and its subsequent treatments, such as somatic treatments, pharmacotherapy, and electroconvulsive therapy. The existential model (B) focuses on the person's experience in the here and now, with much less attention focused on the person's past. The interpersonal model (C) focuses on the belief that behavior evolves around interpersonal relationships. 14. Which client should the nurse identify as the highest risk for the onset of stress-related problems? A. 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. B. 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. C. 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. D. 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 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. 15. The client with depression asks the nurse, What are neurotransmitters? My doctor thinks my problem may lie with the neurotransmitters in my brain. What information should the nurse use to support an explanation of neurotransmitters? A. Chemical messengers that cause brain cells to turn on or off. Correct B. Areas of the brain that are responsible for controlling emotions. C. Clumps of cells that alert the other brain cells to receive messages. D. Web-like structures that provide connections among parts of the brain. Neurotransmitters are chemicals manufactured in the brain that are responsible for exciting or inhibiting brain cells to produce an action (A). Neurons are clumps of cells (C) that alert the other brain cells to receive messages. The limbic system is the area of the brain responsible of controlling emotions (B). Astrocytes are glial cells that are web-like structures that connect blood vessels to neurons in the brain (D). 16. A client is scheduled to complete a positron emission tomography (PET) scan. The client asks the nurse to explain the reason the test was prescribed. How should the nurse respond? A. Images indicate the presence of tumors and scars. B. The scan clearly outlined structures of the brain. C. Results show activity in various portions of the brain. Correct D. PET shows biochemical levels of neurotransmitters. The results of a PET scan (used to detect cerebral activity in depression, schizophrenia, and Alzheimer's disease) shows brightly colored cerebral areas where an accumulation of a radioactively tagged glucose is used as a tracer to visualize brain activity (C), blood flow, and glucose metabolism. (A, B, or D) are not revealed by a PET scan. 17. A client with panic disorder tells the nurse, This illness is awful. I'm frightened that I will always be this way and that there's no hope for me. What is the best information for the nurse to provide? A. Panic disorder is treatable in a number of different ways, including medication. Correct B. Understanding the fact that a cure is not attainable helps the client learn to adjust. C. This disorder is a biologically determined hereditary disease that has no cure. D. Evidence based practice indicates that neuroleptic drugs can be used prophylactically. To foster the client's ability to cope, effective treatment options for panic disorder, such as desensitization, cognitive restructuring, relaxation, and psychotropic medications (A), should be discussed. (B, C, and D) do not provide accurate information. 18. A female client who is admitted for treatment of uncontrolled diabetes mellitus is withdrawn and tearful. She complains she has gained excessive weight because she hates her diet, hates taking insulin, and just wants to be normal again. What therapeutic action should the nurse take? A. Assist the client in verbalizing distress about the disease. B. Inquire about emotional factors affecting the client's present condition. Correct C. Assess priorities to be set for the client's overall nursing care plan. D. Encourage the client to emotionally accept the chronicity of the disease. Holistic care considers biological, psychological, and sociocultural factors that influence one's health status. The client is giving clues to psychological distress, so assessment for emotional factors that have impacted the client's present condition (B) should be made. The client is expressing distress, so (A) is redundant. Although priorities (C) should be determined, the client's current emotional distress should be addressed at this time. (D) is not indicated at this time. 19. Which action is most important for the nurse to implement during the initial interview for a client who is admitted to the mental health unit? A. Establish rapport in each phase of the nurse-client relationship. Correct B. Determine the client's ability to communicate effectively. C. Reflect on previous psychiatric interviews the nurse has performed. D. Ensure data is collected and recorded in a systematic sequence. A client with whom the nurse establishes rapport (A) during the initial interview and in each phase of the nurse-client relationship feels understood by the nurse and is more likely to cooperate and provide feedback during the admission process. Although the ability to communicate (B) is a component of the client's recovery, it is not always needed to establish rapport or maintain a therapeutic relationship. Experience (C) strengthens the therapeutic self, but it not the most important skill used during the initial interview. Systematic collection and documentation of data (D) ensures a comprehensive and complete assessment, which is dependent upon the use of rapport and the therapeutic self. 20. When assessing a client's emotional intelligence, which client capabilities should the nurse focus the interview on with a client diagnosed with a chronic mental illness? A. Linguistic and musical abilities. B. Interpersonal and intrapersonal skills. Correct C. Bodily kinesthetic and spatial abilities. D. Logical mathematics and linguistic abilities. Interpersonal and intrapersonal intelligence form one's personal intelligence or emotional quotient, so the nurse should focus inquiries on social skills (B). (A and D) assesses cognitive and mental status. (C) determines neurophysical interpretation of one's body within the environment, but does not assess emotional intelligence. 21. A female client with severe depression is given information about the risks, benefits, alternatives, and expected outcomes of electroconvulsive therapy (ECT) and signs the informed consent for treatment. After the client's family leaves, the client tells the nurse, I signed the papers because my husband told me I will be deported if my depression is not cured. What information should the nurse report to the healthcare provider? A. The client's consent may have been coerced. Correct B. All the elements of informed consent were met. C. The woman may not fully understand the risks and benefits. D. The client is not competent to sign permission for treatment. Informed consent requires that the choice is freely given. Although the staff acted ethically and observed the client's right to give informed consent, the decision may have been coerced (A) based on family pressure. (B, C, and D) are not accurate. 22. A male client tells the nurse that he plans to kill his spouse and her lover as soon as he is released from the hospital. What action should the nurse implement? A. Keep this information confidential until the client's release. B. Immediately contact the client's spouse and the lover. C. File oral and written reports with the local police department. D. Inform the healthcare provider and document the plan in the record. Correct The Tarasoff decision gives mental health professionals a duty to warn prospective victims, but the extent and discharge of the duty may vary from state to state. The healthcare provider should be notified, and the information documented in the client's record (D). (A) may cause harm to unwitting individuals. Although the scope of practice requires ensuring the safety of the client and others, (B and C) violates client confidentiality and are not indicated. 23. A male client is brought to the emergency department by a police officer, who reports the client was disturbing the peace by running naked in the street, striking out at others, and smashing car windows. Which behaviors should the client demonstrate to determine if he should be evaluated for involuntary commitment? (Choose all that apply.) A. Threats to kill his friend. Correct B. Disruptive behaviors in a community setting. C. Hears voices telling him to kill himself. Correct D. Reports he has not needed a bath in 4 months. Correct E. Created extensive private property damage. F. Says he has not eaten in 3 days. Correct Correct responses are (A, C, D, and F). Most states provide for emergency involuntary hospitalization or civil commitment for a specified period to prevent dangerous behavior that is likely to cause harm to self or others. Police officers and healthcare providers may be designated by statute to authorize the detention of persons who are a danger to themselves or others (A and C) or who are unable to provide for their own basic needs (D and F) due to mental illness. (B and E) are civil issues, not factors related to involuntary commitment. 24. What action should the nurse take when a client who is psychotic proposes goals that are both unrealistic and undesirable? A. Do nothing and remember the client's rights. B. Express doubt that the goal can be achieved. C. Tell the client that the goal is unrealistic. D. Reflect the client's behavior and its consequences. Correct A client who is psychotic is unable to visualizing the consequences of proposed goals, so the use of reflection about the client's behavior and its consequences (D) is the most therapeutic approach. (A) is not therapeutic. Although negative confrontation (B and C) challenge the client's perception of reality, a client who is psychotic is not capable of responsible judgment, and these responses halt therapeutic communication. 25. A client is pacing in the hall near the nurses' station and swearing loudly. What response is best for the nurse to provide? A. Hey, what's going on? B. Others are being distracted. Please, quiet down. C. You seem pretty upset. Tell me about it. Correct D. Please go to your room to get control of yourself. A client who is distressed and acting out angrily should be assessed for additional information about what may be causing a change in the client's behavior. Therapeutic responses to disruptive behavior or language should begin with the nurse's reflective interpretation of the client's distress, and followed with an open-ended statement (C). (A and B) are not client- centered. (D) may prompt additional agitation because it does not recognize or attempt to understand the client's need. 26. A client is responding to auditory hallucinations and shakes a fist at a nurse and says, Back off, witch! The nurse follows the client into the day room. What action should the nurse implement? A. Sit down in a chair near the client. B. Position self within an arm's length of the client. C. Ensure that there is physical space between the nurse and client. Correct D. Move to a position that allows the client to be closest to the room's door. Personal space needs increase when a client feels anxious and threatened, so adequate social space (4 to 12 feet) between the nurse and the client should be maintained to minimize the client's escalation. An arm's length distance from the client (B) may be within the client's intimate space (0 to 1.5 feet) or personal space (1.5 to 3 feet) and increases the risk for physical contact. A posture at the same level of eye contact minimizes a threatening physical presence, so sitting (A) is inadvisable, unless the client is sitting. Allowing the client to block the nurse s exit from the room (D) places the nurse at risk for injury. 27. A male client with severe orthopedic injuries following a motor vehicle collision is irritable, angry, and belittles the nurses. While a nurse is changing the dressing over a laceration, the client screams, Don't touch me! You're so stupid that you'll make it worse! Which intervention is best for the nurse to implement? A. Leave the room without saying a word. B. Provide information about infection prevention. Correct C. Allow the client to change the dressing himself. D. Explain the healthcare provider's prescription. Several factors impact a client with anger, which is a cognitively driven problem. The correct nursing intervention helps the client test cognition and may lead to lowering anger, which impacts the client's readiness for acceptance of the nurse's interventions in providing care. Since the dressing change is initiated, making the client aware of why the dressing change is necessary (B) is therapeutic to forming a relationship. The feelings of powerlessness that are currently being expressed through anger only escalate if the nurse offers no alternatives to addressing the presenting issues (A or D). (C) is not therapeutic. 28. A 35-year-old married woman works full-time in a factory and has been absent from work for three days at a time on several occasions. Each time she returns to work, she wears dark glasses to cover facial bruising. Her supervisor refers her to the occupational health nurse. What assessment question is most important for the nurse to initially use? A. Do you drink excessively? B. Did your husband beat you? C. How did this happen to you? Correct D. What did you do to deserve this? Domestic violence can present in several forms, including sexual, physical, mental, and neglect. The victim of spousal abuse is often frightened or may feel at fault about the abuse, so a therapeutic relationship should be established with the client using non-judgmental, open- ended questions, such as (C), so the client is comfortable to disclose details about the injury, if abuse is suspected. (A and B) are close-ended questions that can be answered with yes or no answers. (D) implies fault and is not therapeutic. 29. A female client presents to the emergency center with confusion, emotional numbness, and expresses to the nurse a feeling of disbelief that she was raped. The nurse determines the client is in the acute phase of rape-trauma syndrome. What action should the nurse implement first? A. Secure samples of vaginal hair combings. B. Offer prophylactic antibiotic medication. C. Explain the rape protocol to the client. Correct D. Implement crisis intervention counseling. Impact reactions of the acute phase of the rape-trauma syndrome include shock, emotional numbness, confusion, disbelief, restless, and agitated motor activity, so explanation of the forensic rape protocol (C) and permission to proceed with examination should be provided first to minimize additional trauma during assessment and the collection of evidence (A). After the collection of evidence, prophylactic antibiotic medication (B) is provided and then crisis intervention counseling initiated (D). 30. Which client outcome indicates improvement for a client who is admitted with auditory hallucinations? A. Argues with the voices. B. Tells when voices decrease. Correct C. Follows what the voices say. D. Tells the nurse what the voices say. Hallucinations are defined as false sensory perceptions, and the goal of nursing interventions with clients who are hallucinating is to help them to increase awareness of their symptoms (B) and distinguish between the world of psychosis and reality. Arguing with the voices (A) and following the directions of the voices (C) indicates that the client is consumed by altered reality, which may place the client at risk for self-harm or danger to others. (D) provides the nurse with information about the client's risk for self-injury. 31. The nurse is caring for an adult male client with catatonic schizophrenia who is mute and motionless. What is the priority nursing diagnosis? A. Impaired mobility. B. Ineffective individual coping. C. Impaired verbal communication. D. 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. 32. A client with a history of alcoholism is admitted with a compound fracture of the femur after falling down the previous night. What additional assessment should be the priority focus for the nurse? A. Collect a specimen for a blood alcohol level (BAL). B. Do nothing because the time for BAL determination is passed. C. Review the results of a Breathalyzer obtained in the emergency department upon admission. D. Ask the client about the quantity, frequency, and time the last alcohol drink was ingested. Correct The priority assessment is to determine the client's risk for alcohol withdrawal, which can appear within 48 hours since the ingestion of the last alcoholic drink, so (D) is priority. (A) is not indicated at this time. The client with a history of alcoholism is at risk for delirium tremens (DT), which can develop within 48 to 96 hours of the last drink, and should be monitored for symptoms of confusion, hallucinations, and severe autonomic nervous system hyperactivity, not (B). Although (C) may provide data that confirms recent alcohol ingestion, it does not provide historical client information that may indicate the client's risk for DT, a life-threatening syndrome. 33. A client who is intoxicated is admitted for alcohol and multiple substance detoxification. The nurse determines that the client is becoming increasingly anxious, agitated, and diaphoretic. The client is also experiencing sensory perceptual disturbances and a clouded sensorium. What is the priority nursing intervention for this client at this time? A. Check on the client every 15 minutes. B. Begin one-on-one supervision immediately. Correct C. Keep the room dimly lit and turn on the radio. D. Push fluids and provide calorie-rich nutritional supplements. One-on-one supervision (B) ensures the client's physical safety until the client is sedated adequately to reduce feelings of terror and tactile and visual hallucinations. Checking every 15 minutes (A) does not provide sufficient assessment of the client's safety. Additional auditory stimulation and a dimly lit room (C) can create illusions that contribute to the client's altered sensory distress and should be avoided. Fluid replacement and nutritional supplements (D) should be initiated when the client is more stable because the risk for overhydration can occur as blood alcohol levels fall and fluids are retained. 34. A female client comes to an outpatient therapy appointment intoxicated. The spouse tells the nurse, There wasn't anything I could do to stop her drinking this morning. What intervention should the nurse take at this time? A. Arrange for emergency admission to a detoxification unit. B. Talk to the spouse about strategies to limit the client's drinking. C. Have the client admitted to the inpatient psychiatric unit. D. Tell the client that therapy cannot take place while she is intoxicated. Correct Therapy sessions are designed to confront the issues that the client with alcohol dependence may be experiencing. If the client presents inebriated, a therapeutic and confrontational meeting cannot occur (D) because the client's judgment is altered. (A and C) are not necessary at this time. (B) is ineffective. 35. Which client statement should the nurse identify as most typical of a client with mania? A. I can't do anything anymore. B. I can't understand where all our money goes. C. I manage our finances great because I buy in big quantities. Correct D. I wonder why my wife is so upset that I spend money easily. A client with bipolar disorder, mania, characteristically demonstrates thoughts of inflated self- esteem, grandiosity, and a tendency for excessiveness, such as excessive spending (C). (A) is a statement of dispair that is more likely made by a client with depression. Although a client with mania may lack insight (B) regarding the impact that excessive, bizarre behaviors have on the lives around them (D), the diagnostic criteria that hallmarks mania is excessive involvement in pleasurable activities with painful consequences. 36. What nursing assessment is the priority focus for a client with major depression? A. Mood and affect. B. Suicidal ideation. Correct C. Nutritional status. D. Fluid and electrolyte balance. Suicidal ideation (B) is a major risk factor in a client with major depression. Although mood and affect (A) are assessed while determining if the client has suicidal ideations, the client's risk for self-injury is the priority. Nutritional status (C) should be assessed at a later point in the initial assessment. Fluid and electrolyte balance (D) should be confirmed by evaluation of admission laboratory results. 37. The nurse is caring for a client who received the first-time electroconvulsive therapy (ECT) a half hour ago. Which action should the nurse implement first? A. Offer oral fluids. B. Monitor vital signs. Correct C. Evaluate ECT effectiveness. D. Encourage group participation. Sedatives, muscle relaxants, and an anticholinergic agent are often prescribed for the client during ECT. Vital signs (B) should be monitored during recovery after the ECT procedure. Oral fluids (A) should be withheld until the client is alert and oriented to avoid the risk of aspiration. Improvement in mood or affect (C) may not be apparent for several weeks. Confusion and memory loss may be an initial reaction experienced by some clients, so group interaction (D) is not indicated in the immediate hours after recovery. 38. A client with substance abuse is admitted to the mental health unit. Which action should be implemented by the nurse, and not delegated to a unlicensed assistive personnel (UAP)? A. Provide menus for dietary selections. B. Clarify visiting hours and telephone usage. C. Collect a complete substance abuse history. Correct D. Obtain vital signs and orient the client to the unit. As part of a comprehensive assessment, the nurse should assess the client for past and present alcohol, tobacco, prescription drug, over-the-counter drug, and illicit drug use (C). The UAP is qualified to provide the client with menus for dietary selection (A), clarify unit policies including visiting hours and telephone use (B), obtain vital signs and orient the client to the unit (D). 39. Which action should the nurse implement first for a client experiencing alcohol withdrawal? A. Apply vest or extremity restraints. B. Give an alpha-adrenergic blocker. C. Provide a diet high in protein and calories. D. Prepare the environment to prevent self-injury. Correct Self-destructive or violent behavior provides a potentially immediate and life-threatening risk to the client and others, so a safe environment should be provided (D) by removing any potential objects that could inflict self-injury. Secondary prevention strategies (frequent orientation to surroundings, restraints to prevent self-injury (A), and the administration of antianxiety agents or alpha-adrenergic blockers (B) for hallucinations, delusions, confusion, and agitation) should then be implemented. Once the client is stabilized, nutritional issues (C) should be addressed. 40. The nurse is caring for a client who was admitted for alcohol detoxification 2 days ago. Which finding is most critical for the nurse to report to the healthcare provider? A. Restlessness, anxiety, and difficulty sleeping. B. Global confusion and inability to recognize family members. Correct C. Agitation, vomiting, and visual and auditory hallucinations. D. Low-grade fever, diaphoresis, hypertension, and tachycardia. Delirium tremens (DT) or alcohol withdrawal delirium usually peaks 2 to 3 days (48 to 72 hours) after cessation or reduction of intake (although it can occur later) and lasts 2 to 3 days. The risk of DT carries a 2% to 5% mortality rate, so this critical syndrome of alcohol withdrawal, manifested as global confusion and an inability to recognize family members (B), is life- threatening and requires emergency medical intervention. The early signs of withdrawal (A) develop within a few hours after cessation or reduction of alcohol (ethanol) intake; the signs peak after 24 to 48 hours (C and D) and then rapidly and dramatically disappear, unless the withdrawal progresses to alcohol withdrawal delirium. 41. During a one-to-one interaction, a male client describes the sadness he experienced when his mother died. Suddenly, the nurse begins to think about her grandmother's death. As a result, the nurse asked the client to describe his thoughts when he learned of his own mother's illness. What is the nurse doing? A. Reflection. B. Clarification. C. Self-Awareness. Correct D. Focusing. Self-awareness (C) defines the nurse's awareness of his or her own feelings while empathizing with the client. (A) involves restating what the client is saying. (B) involves asking the client to explain feelings more specifically. (D) directs the client to focus on emotional or behavioral responses to feelings. 42. 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? A. I do OK as long as I can get methadone from the clinic regularly. B. By learning what led to my latest relapse, I know what to do in the future. Correct C. A 12-step program is the only treatment approach that is proven effective. D. I know now that I wasn't ready to make a change until I hit rock bottom. 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 (B). Methadone treatment is not indicated for all substance abusers, only those addicted to opiates, and enrollment in this type of program does not necessarily mean that the client is committed to recovery (A). While 12-step programs are known to work, there are many other effective treatment approaches (C). Client readiness is highly individualized, and can stem from a variety of experiences and situations, so hitting rock bottom is not necessary before clients can attempt recovery (D). 43. A female client with bipolar disorder, manic phase, is planning weekend activities with the other clients on the unit. The client interrupts the group, insists that they change their plans to a disco party, and begins to curse loudly when the group refuses to change the plans. Which intervention should the nurse implement? A. Tell the client to quiet down. B. Escort the client to a quieter place. Correct C. Ask the group to reconsider the suggestion. D. Ignore the client's manic outbursts. A client in the manic phase has an inflated ego, feelings of grandiosity, and is unlikely to respond to limit-setting. To curtail further escalation and disruption, the client should be escorted to a less stimulating environment (B). (A) is ineffective because a client in the manic phase is often unable to control their behavior. The group decision should be supported, not (C). Ignoring the client's outbursts (D) frequently leads to escalation of the behaviors and increases the client's risk of self-injury or injury of others. 44. Which action should the nurse implement during the termination phase of the nurse- client relationship? A. Identify new problem areas. B. Confront changes not completed. C. Explore the client's past in depth. D. Help summarize accomplishments. Correct By noting the client's accomplishments (D), the client's progress and self-confidence can be summarized. The working phase focuses on identifying new problem areas (A) and confronting necessary changes (B). The orientation phase includes an in-depth assessment of the client, including past history (C). 45. Which statement made by an adolescent in group therapy should the nurse identify as a priority in planning care? A. If I fail another class, I'm going to kill myself. B. I have a necktie in my room that I can use to hang myself. Correct C. When I leave home to live on my own, I'm buying myself a gun. D. I took two bottles of Mom's pills and had to have my stomach pumped. Assessment of suicidal ideations should include the degree of lethality of the method, the individual's access to whatever is needed to carry out the attempt, and the specifics of the plan. The more detailed the plan, the greater the risk for a successful attempt. A necktie in the adolescent's room (B) implies a lethal plan with an accessible, available means to act and implement a suicidal ideation. (A and C) are expressions of future suicidal plans with stipulations, which allows time for intervention. (D) is an historical account of a suicidal attempt. 46. The nurse is caring for a female client who is admitted for depression with the nursing diagnosis, Self-esteem, chronic low. Which client response indicates to the nurse that the client has improved self-esteem? A. Identifies own strengths. Correct B. Stops crying during every session. C. Talks with other clients about marital advice. D. Asks the nurse if her behavior has improved. 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. 47. During an inpatient therapy group session, a client tells the members that he hears voices that say his doctor is going to poison him. He continues, "I look around to see who's talking to me, and I can't see anybody." Another client replies, "I used to hear voices, too. I found out they were my imagination. The voices you hear aren't real either." Which phenomenon, common to groups, is exemplified in this interchange? A. Catharsis. B. Ventilation. C. Universality. D. Reality testing. Correct Reality testing is a process in which an individual validates one's perception of reality. Group members can provide reality testing (D) by monitoring each member's reactions and behaviors and providing feedback in an open and nonthreatening manner. In group therapy, catharsis (A) is the release of intense, overwhelming emotions that members learn to express and experience immediate relief. Group members experience universality (C) through awareness that they are not unique and others have reactions and thoughts similar to their own. Ventilation (B) is the verbalization of impulsive or negative feelings that reduces the risk of acting-out behaviors. 48. An adolescent who attempted suicide with a drug overdose arrives in the emergency department with an empty 30-tablet bottle of acetaminophen (Tylenol). Which action should the nurse implement? A. Administer acetylcysteine (Mucocyst). Correct B. Monitor cardiac rhythm for flat T waves. C. Check both serum AST and ALT levels. D. Prepare to administer Syrup of Ipecac. Tylenol overdose is treated with immediate administration of Mucomyst (A) to prevent hepatic insult. Tylenol is not cardiotoxic, so (B) is not indicated. Although (C) provides a baseline evaluation of hepatic function, the priority is antidotal drug treatment. (D) may interfere with the therapeutic use of Mucomyst and is not indicated. 49. A client on the mental health unit reports concerns about weight gain as a result of taking divalproex (Depakote) and requests assistance to fill out a menu. The nurse should initiate a referral to which healthcare team member? A. Occupational therapist. B. Recreational therapist. C. Dietician. Correct D. Physician. The nurse should ask for a referral to the dietician (C) who can assist the client with meal planning for weight reduction. (A and B) do not give guidance about meal planning. (D) can prescribe a special diet or talk to the client about the medication, but concerns about meal planning and weight gain should be addressed by the dietician. 50. During the admission of a male client to the mental health unit, the client tells the nurse that he had a panic attack today and ran out of the physician's office. Which question is most important for the nurse to ask this client? A. On a scale of 1 to 10 how do you rate your anxiety level? B. How would you describe your mood right now? C. Have you had any thoughts of hurting yourself? Correct D. What medications have you taken in the last 24 hours? Assessing for suicidal ideation (C) is most essential. Asking the client to rate anxiety (A) and mood (B), and obtaining a medication history (D) are important, but assessing for thoughts of self-harm is most important because it involves client safety. 51. The daughter of a female client with stage-1 Alzheimer's disease (AD) asks the nurse what changes should she expect her mother to demonstrate in this stage. What finding should the nurse tell the daughter is common? A. Inability to recognize one's location. Correct B. Personality changes and agitation. C. Depression and emotional lability. D. Alterations in communication. Evidence indicates that frequent incidences of confusion, such as being unable to recognize one's location (A) in a familiar environment is associated with the early stages of Alzheimer's Disease. (B, C, and D) occur with later stages of AD. 15. 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? A. Place the client in mechanical restraints until calm. Correct B. Administer a PRN dose of haloperidol (Haldol) IM. C. Use a calm, soothing voice to diffuse the situation. D. Encourage the client to focus on his feelings of anger. 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 16. During an admission assessment interview, a client states, "I do not use many drugs." How should the nurse respond? A. "Tell me about the drugs you use now." Correct B. "Explain what you mean by many drugs." C. "Do you mean legal drugs or illegal ones?" D. "What kind of drugs are you talking about?" Open-ended questioning (A) allows the client provide specific information without probing. (B) is critical of the client's descriptors and does not encourage further dialog. (C and D) are close- ended questions that require one word responses, and stop further exploration with the client. [Show More]

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