RN HESI Mental Health with NGN
RN HESI Mental Health with NGN
Total Questions : 51
Showing 10 questions Sign up for moreThe occupational health nurse is working with an employee who was just notified that their child was involved in a motor vehicle collision and taken to the hospital. The employee states, "I can't believe this. What should I do?" Which response is best for the nurse to provide in this crisis?
Explanation
Choice A rationale: Asking the client what they think should happen is vague and does not offer any direction or support.
Choice B rationale: This response encourages is vague and does not offer any direction or support but instead puts the burden of decision-making on the client who is overwhelmed and distressed.
Choice C rationale: Inquiring about the seriousness of the collision is important but may not be the most immediate concern when the client is seeking guidance on what to do.
Choice D rationale: This response shows empathy and concern for the client's well-being and helps the client take action to cope with the crisis.
A client is admitted to the psychiatric inpatient unit with a bandaged flesh wound after attempting self injury by shooting. The client reports going through a divorce one year ago, job loss four months ago, and suffering from a breakup of a current relationship last week. Which is the most likely source of this client's current feelings of depression?
Explanation
Choice A rationale: While frustration may contribute to distress, the client's recent life events, such as a breakup and job loss, suggest a stronger link to a sense of loss.
Choice B rationale: Experiencing a divorce, job loss, and recent breakup are significant life events that contribute to a profound sense of loss, which can lead to feelings of depression.
Choice C rationale: Poor self-esteem can contribute to depression, but the client's recent life events are more directly related to the current feelings of depression.
Choice D rationale: While a lack of intimate relationships can impact mental health, the recent breakup is a more immediate factor contributing to the client's depression.
A woman who attends a stress management group reveals to group members that though she recently divorced, she continues to care for her husband's aging parents. Which psychological mechanism should the nurse address in the plan of care?
Explanation
Choice A rationale: Altruism involves addressing one's own needs through meeting the needs of others, and caring for the husband's aging parents is an example of this coping mechanism.
Choice B rationale: Regression involves reverting to an earlier stage of development, which is not evident in the scenario.
Choice C rationale: Compartmentalization is the defense mechanism of separating conflicting thoughts or feelings, which is not clearly identified in the scenario. Choice D rationale: Egocentrism involves seeing the world from only one's own perspective, which is not the primary issue in the scenario.
The nurse interacts with a client who is very depressed and slow to respond to questions. The nurse asks the client to describe current feelings, but the client looks down at the table. Which action is best for the nurse to implement?
Explanation
Choice A rationale: Waiting for the client to respond allows for a patient-centered approach, respecting the client's pace and giving them the opportunity to express themselves when ready.
Choice B rationale: Assuming the client's ability to hear the question may be accurate, but the client's nonverbal cues suggest a need for patience and a non-coercive approach.
Choice C rationale: Changing the question may not address the client's current feelings and might disrupt the therapeutic process.
Choice D rationale: Returning at a later time might be appropriate if the client continues to be unresponsive, but it is not the initial action in this situation.
A young adult client is admitted to a psychiatric facility with a diagnosis of bulimia nervosa. Which nursing intervention has the highest priority?
Explanation
Choice A rationale: Monitoring for binging activities is important, but addressing the potential physiological complications of bulimia, such as electrolyte imbalances, takes precedence.
Choice B rationale: Assessing and reporting the client's electrolyte status is the highest priority as bulimia nervosa can lead to severe electrolyte imbalances, which may result in life-threatening complications.
Choice C rationale: Assigning care based on age is not a priority in addressing the immediate health risks associated with bulimia nervosa.
Choice D rationale: While group therapy is beneficial, addressing the client's physical health and safety is the highest priority.
A client with chronic alcohol dependence is diagnosed with Wernicke-Korsakoff syndrome. The client is experiencing memory loss and confusion. Which medication should the nurse administer to help alleviate the client's symptoms?
Explanation
Choice A rationale: Thiamine (vitamin B1) is the appropriate medication for Wernicke Korsakoff syndrome, as it addresses thiamine deficiency associated with chronic alcohol use, which can contribute to neurological symptoms.
Choice B rationale: Chlordiazepoxide is a benzodiazepine used for alcohol withdrawal symptoms but does not address the underlying thiamine deficiency in Wernicke Korsakoff syndrome.
Choice C rationale: Clonidine is not indicated for the treatment of Wernicke-Korsakoff syndrome; it is primarily used for managing withdrawal symptoms in opioid or alcohol dependence.
Choice D rationale: Carbamazepine is not the appropriate medication for Wernicke Korsakoff syndrome; it is commonly used for mood stabilization in conditions like bipolar disorder.
The nurse is preparing a client for discharge after treatment for cocaine abuse. The client is taking home a prescription for a new medication to control cocaine cravings. Which intervention is most important for the nurse to implement?
Explanation
Choice A rationale: While assessing for symptoms of cocaine withdrawal is important, educating the client about the purpose and side effects of the medication is the priority when initiating new pharmacological treatment.
Choice B rationale: Educating the client about the purpose and side effects of the medication promotes understanding and adherence to the treatment plan, addressing the client's cravings.
Choice C rationale: Encouraging the client to take the medication as prescribed is important, but educating them about the medication takes precedence.
Choice D rationale: Determining when the client last used cocaine is relevant but does not directly address the education needed for medication management.
The nurse is planning the care for a client who is hospitalized with a bipolar disorder. The client wanders the hallways, talks excessively, and makes sexual comments about the staff. Which intervention(s) should the nurse include in the plan of care? Select all that apply.
Explanation
Choice A rationale: Giving concise and firm directions for hygiene and dressing helps provide structure and support during periods of manic behavior.
Choice B rationale: Engaging the client in competitive activities may exacerbate manic symptoms, so it is not the best approach.
Choice C rationale: Assigning the client to a single room provides a quieter and less stimulating environment, promoting a more controlled and therapeutic setting. Choice D rationale: Inviting the client for a walk when their energy is high allows for a structured outlet for excess energy and may help with symptom management.
Choice E rationale: Providing television programs with suspense may contribute to overstimulation and is not the best approach during manic episodes.
Two days after being admitted with alcohol withdrawal, a client has constant liquid stools and abdominal cramping. The emesis and stool are hemoccult positive. The client is confused and refusing to take oral medication. Which action should the nurse implement first?
Explanation
Choice A rationale: Administering an antianxiolytic medication may be appropriate, but addressing the client's fluid and electrolyte imbalance is the priority.
Choice B rationale: Inserting a fecal management tube is not the first action to take in response to hemoccult positive liquid stools; addressing fluid balance is more urgent.
Choice C rationale: Inserting a peripheral intravenous catheter is the priority to address the client's fluid and electrolyte imbalance and provide necessary hydration and medications.
Choice D rationale: Crushing pills and placing them in applesauce may be considered, but the client's fluid and electrolyte imbalance needs prompt attention first.
During admission to the psychiatric unit, a client is extremely anxious and reports being worried about the sun coming up the next day. Which intervention is most important for the nurse to implement during the admission process?
Explanation
Choice A rationale: Remaining calm and using a matter-of-fact approach helps provide a sense of security and reduces anxiety in the client during admission.
Choice B rationale: Assisting the client in developing alternative coping skills is important but may not be the first action during the initial admission process.
Choice C rationale: Administering a sedative may be considered if the client's anxiety is severe, but understanding and addressing the underlying cause of anxiety is the priority.
Choice D rationale: Asking the client why she is anxious may be appropriate, but the initial focus is on providing a calming and supportive environment during admission.
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