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HESI Mental Health
1. A male client with alcohol use disorder is admitted for detoxification. The nurse knows that which symptom is a sign of severe alcohol withdrawal?
- A. Bradycardia
- B. Seizures
- C. Hyperglycemia
- D. Constipation
Correct answer: B
Rationale: Seizures are a sign of severe alcohol withdrawal and can be life-threatening, requiring immediate medical attention. Bradycardia, hyperglycemia, and constipation are not typically associated with severe alcohol withdrawal. Bradycardia is more commonly seen in opioid withdrawal, hyperglycemia could be due to other reasons like uncontrolled diabetes, and constipation is not a typical symptom of severe alcohol withdrawal.
2. A client with schizophrenia is experiencing auditory hallucinations. What is the most appropriate nursing intervention?
- A. Encourage the client to focus on reality-based activities.
- B. Tell the client that the voices are not real.
- C. Ask the client to describe the voices he hears.
- D. Encourage the client to interact with others who are not experiencing hallucinations.
Correct answer: A
Rationale: The most appropriate nursing intervention for a client with schizophrenia experiencing auditory hallucinations is to encourage the client to focus on reality-based activities. This intervention helps redirect their attention away from hallucinations, promoting engagement with the environment. Choice B is incorrect as telling the client that the voices are not real may invalidate their experiences and worsen the therapeutic relationship. Choice C may increase the client's distress by focusing on the hallucinations. Choice D might not be helpful as interacting with others who are not experiencing hallucinations may not address the client's current needs.
3. A male client with delirium becomes disoriented and confused in his room at night. The best initial nursing intervention is to:
- A. Move the client next to the nurse's station
- B. Use an indirect light source and turn off the television
- C. Keep the television and a soft light on during the night
- D. Play soft music during the night, and maintain a well-lit room
Correct answer: B
Rationale: The best initial nursing intervention for a male client with delirium who becomes disoriented and confused in his room at night is to use an indirect light source and turn off the television. This approach helps to reduce stimulation and confusion, aiding in the client's orientation and comfort. Moving the client next to the nurse's station (Choice A) may not address the root cause of disorientation and could disrupt the client's routine. Keeping the television and a soft light on (Choice C) may further contribute to the client's confusion. Playing soft music and maintaining a well-lit room (Choice D) may not be as effective in reducing stimulation and promoting orientation as using an indirect light source and turning off the television.
4. A 25-year-old female client has been particularly restless, and the nurse finds her trying to leave the psychiatric unit. She tells the nurse, 'Please let me go! I must leave because the secret police are after me.' Which 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.
Correct answer: D
Rationale: In this scenario, the best response for the nurse is to offer presence and a safe environment without validating the delusion or arguing with the client. By inviting the client to the room and offering to sit with her, the nurse is providing support and reassurance. Choice A is incorrect because directly denying the client's belief may escalate the situation. Choice B is inappropriate as it dismisses the client's concerns without addressing the underlying issue. Choice C acknowledges the client's feelings but does not provide immediate support or safety, unlike Choice D which offers both.
5. A male client with alcohol dependence is admitted for detoxification. The nurse knows that which assessment finding is indicative of alcohol withdrawal?
- A. Bradycardia
- B. Hypotension
- C. Tremors
- D. Hyperglycemia
Correct answer: C
Rationale: Tremors are a common sign of alcohol withdrawal. The central nervous system becomes hyperexcitable due to the suppression caused by chronic alcohol intake. Tremors are a manifestation of this hyperexcitability and are a key indicator of alcohol withdrawal. Bradycardia and hypotension are more commonly associated with conditions like shock or severe dehydration rather than alcohol withdrawal. Hyperglycemia is not a typical finding in alcohol withdrawal; instead, hypoglycemia is more commonly seen due to the effects of alcohol on glucose metabolism.
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