Mental Health HESI

HESI RN

1. A female client on a psychiatric unit is sweating profusely while vigorously doing push-ups and then running the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbance, the client shouts, â€œI am the boss here. I do what I want.â€ Which nursing problem best supports these observations?

A. Deficient diversional activity related to excess energy level.
B. Disturbed personal identity related to grandiosity.
C. Risk for activity intolerance related to hyperactivity.
D. Risk for other-directed violence related to disruptive behaviors.

Correct answer: D

Rationale: The client's behavior of engaging in disruptive and aggressive actions, as well as claiming authority over others in the setting, indicates a risk for other-directed violence. This behavior poses a potential threat to the safety of others in the environment. Choice A is incorrect as the client's behavior is not solely indicative of a lack of diversional activities but rather a more serious issue. Choice B is incorrect as the behavior described does not primarily reflect disturbances in personal identity but rather displays of power and aggression. Choice C is incorrect as the client's actions do not suggest an intolerance to activity but rather an excessive and potentially harmful level of hyperactivity.

2. A client with anorexia nervosa has a body mass index (BMI) of 16.5 and has been diagnosed with bradycardia. Which of the following findings should the RN be most concerned about?

A. Body temperature of 96.8Â°F.
B. Heart rate of 52 BPM.
C. Serum potassium level of 4.1 mEq/L.
D. Electrocardiogram (ECG) changes.

Correct answer: D

Rationale: In a client with anorexia nervosa and bradycardia, monitoring for ECG changes is crucial as these changes may indicate potentially life-threatening cardiac complications. While other findings like low body temperature, bradycardia, and serum potassium levels are concerning, ECG changes specifically reflect the impact of bradycardia on the heart's electrical activity and should be the priority for the nurse to assess and address.

3. What assessment questions should the nurse ask when attempting to determine a teenagerâ€™s mental health resilience? Select all that apply.

A. How did you cope when your father deployed with the Army for a year in Iraq?
B. Who did you go to for advice while your father was away for a year in Iraq?
C. How do you feel about talking to a mental health counselor?
D. Where do you see yourself in 10 years?

Correct answer: C

Rationale: The question 'How do you feel about talking to a mental health counselor?' is the most appropriate to assess the teenager's mental health resilience as it directly addresses their willingness to seek help and cope effectively. Choices A and B focus on coping mechanisms during a specific event, which may not reflect the teenager's overall resilience. Choice D is more related to future aspirations rather than assessing current mental health resilience.

4. When preparing to administer a prescribed medication to a homeless male at a community psychiatric clinic, the client tells the nurse that he usually takes a different dosage. What action should the nurse take?

A. Tell him to take the medication then verify the dosage at the next healthcare team meeting.
B. Withhold the medication until the dosage can be confirmed.
C. Inform him that he may refuse the medication and document whether or not he takes it.
D. Explain to the client that the dosage has been changed.

Correct answer: B

Rationale: Withholding the medication until the dosage can be confirmed ensures patient safety and accuracy in treatment.

5. A client who has agoraphobia (a fear of crowds) is starting desensitization therapy with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care?

A. Encourage the substitution of positive thoughts for negative ones.
B. Establish trust by providing a calm, safe environment.
C. Gradually expose the client to larger crowds.
D. Encourage deep breathing when anxiety escalates in a crowd.

Correct answer: B

Rationale: Establishing trust by providing a calm and safe environment is crucial for the success of desensitization therapy in clients with agoraphobia. This approach helps the client feel safe and secure, allowing them to gradually confront their fear of crowds. Encouraging positive thoughts (choice A) is beneficial but not as immediately critical as creating a safe space. Progressively exposing the client to larger crowds (choice C) should occur after trust is established and in a controlled manner. Encouraging deep breathing (choice D) is helpful, but creating a safe environment takes precedence to build a foundation for successful desensitization.