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Hesi rn psychology proctored exam (mental health)
Total Questions : 59
Showing 10 questions, Sign in for moreThe nurse is performing the admission assessment for a client with schizophrenia in an acute care inpatient facility. The nurse should identify which observed behavior is characteristic of schizophrenia?
The nurse is assessing a client whose spouse died of a stroke two weeks ago and who reports having numbness and tingling on the right side of the body. The nurse should consider the client's symptoms may likely be due to which condition?
The client is a 24-year-old male who recently started experiencing hallucinations and disorganized speech.
Day 1
0800
The client is agitated and pacing. He reports that he is hearing voices. He has no intent to hurt himself or others. Haloperidol given as prescribed.
1600
Haloperidol given as prescribed.
Day 2
0000
Haloperidol given as prescribed. The client reports that he has not been hearing strange voices.
0800
Haloperidol given as prescribed. The client reports that he is not hungry this morning.
1600
Haloperidol given as prescribed. The client engaged in the day room today and was interacting well with other clients.
Day 3
Haloperidol given as prescribed. The client returned to sleep after the dosage.
0400
The client was awakened by painful spasms of his back, neck, and tongue. His head is arching backward. He reports that his pain is 8 on a 0 to 10 scale.
Patient Data
Review H and P, nurse's notes, and prescriptions.
Drag one condition and two nursing actions to complete the sentence.
The client is showing signs of
Explanation
• Acute dystonia: The client developed sudden, painful muscle spasms of the neck, back, and tongue with arching of the head shortly after repeated haloperidol doses. These symptoms are classic for an acute dystonic reaction, an extrapyramidal side effect of high-potency antipsychotics. Onset occurs within hours to days of starting or increasing the medication. The sustained muscle contractions and severity of pain strongly support this diagnosis.
• Pseudoparkinsonism: Pseudoparkinsonism presents with tremors, shuffling gait, rigidity, and bradykinesia rather than sudden painful spasms. It develops more gradually compared to acute dystonia. The dramatic arching of the head and tongue involvement are more characteristic of dystonia. The client’s acute onset and severe muscle contractions do not align with parkinsons.
• Electrolyte imbalance: There is no evidence of laboratory abnormalities, dehydration, or symptoms such as generalized weakness or cardiac irregularities. The temporal relationship to haloperidol administration strongly suggests a medication side effect. Electrolyte imbalances present with broader neuromuscular or cardiac symptoms rather than focal dystonic posturing.
• Anaphylaxis: Anaphylaxis would present with hypotension, rash, airway swelling, wheezing, or cardiovascular instability. The client’s symptoms are isolated to muscle spasms without signs of allergic reaction. Vital signs and respiratory findings do not suggest systemic hypersensitivity. The presentation is neurological rather than immunologic.
• Akathisia: Akathisia is characterized by inner restlessness and an inability to remain still, not sustained muscle contractions. Clients often pace or report feeling unable to sit quietly. Painful spasms and abnormal posturing are not typical features. The client’s symptoms are clearly dystonic rather than restlessness-based.
• Administer diphenhydramine: Diphenhydramine is an anticholinergic agent used to rapidly reverse acute dystonic reactions caused by dopamine blockade. It restores the dopamine-acetylcholine balance in the basal ganglia, relieving muscle rigidity and spasms. Prompt administration reduces pain and prevents progression of symptoms.
• Monitor the client's airway: Dystonic reactions can involve the tongue, throat, and laryngeal muscles, potentially compromising the airway. Monitoring ensures early detection of respiratory distress or obstruction. Severe laryngospasm can become life-threatening if not promptly recognized. Close airway assessment is therefore a critical safety priority during acute dystonia.
• Give an extra dose of the antipsychotic: Increasing the antipsychotic would likely worsen the extrapyramidal symptoms by further blocking dopamine receptors. This action could intensify muscle rigidity and spasms. Management requires reducing dopamine blockade effects, not increasing them. Continuing the same medication may lead to further complications.
• Start the client on magnesium supplements: Magnesium supplementation is used for certain electrolyte deficiencies, not medication-induced dystonia. There is no data indicating hypomagnesemia or other deficiencies. The muscle spasms are linked to dopamine imbalance rather than mineral deficiency. This intervention would not resolve the acute symptoms.
• Teach the client about foods with high potassium: Potassium imbalance presents with muscle weakness or cardiac arrhythmias, not focal dystonic contractions. There is no evidence of laboratory abnormalities requiring dietary adjustment. Education about potassium intake does not address the current acute neurological reaction.
Naloxone is administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate. Within 15 minutes, the client is alert and oriented. While planning nursing care, which intervention has the highest priority at this time?
A young female client is admitted to the emergency department because she was raped that evening by her date. Which computer documentation should the nurse enter in the electronic medical record (EMR) as the client's chief concern?
A high school girl reveals to the school nurse that she has been engaging in self-induced vomiting as a weight-control measure. Which initial assessment should the nurse focus on with this adolescent?
A client who was admitted 3 days ago for a bowel obstruction has a liter of lactated Ringer's with potassium chloride (KCI) 20 mEq infusing. The client has been receiving selegiline for depression. When the client reports experiencing a severe headache, the nurse obtains a blood pressure of 200/110 mm Hg. Which action(s) should the nurse take? Select all that apply.
The nurse is assessing a client with paranoia. Which behavior can this client be expected to exhibit?
The nurse is performing intake interviews at a psychiatric clinic. A female client with a known history of drug abuse reports that she had a heart attack four years ago. Use of which substance places the client at highest risk for myocardial infarction?
A female client presents in the emergency department (ED) and states, "I was raped tonight." Which intervention is most important for the nurse to implement?
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