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Nursing Elites

HESI RN

Mental Health HESI

1. To provide effective care for a patient diagnosed with schizophrenia, what associated condition should the nurse frequently assess for? Select all that apply.

Correct answer: A

Rationale: Alcohol use disorder is commonly associated with schizophrenia, leading to a dual diagnosis. Assessing for alcohol use disorder is crucial in managing the patient's overall well-being and treatment plan. Major depressive disorder can co-occur with schizophrenia but is not the most commonly associated condition. Stomach cancer is not typically associated with schizophrenia. Polydipsia, excessive thirst, can be a symptom in some individuals with schizophrenia due to medication side effects, but it is not an associated condition that requires frequent assessment compared to alcohol use disorder.

2. The nurse is developing unit policies that will include nursing guidelines for maintaining a therapeutic milieu. Which interventions should be included when providing a therapeutic milieu in an inpatient setting?

Correct answer: C

Rationale: The nurse is responsible for maintaining a therapeutic milieu in an inpatient setting, which involves creating a secure and structured environment that promotes client safety and offers opportunities for clients to learn healthy coping skills. Regularly scheduled unit activities for peer interaction help foster socialization, support, and a sense of community among clients. Choices A and B are valuable interventions in mental health care but do not directly relate to creating a therapeutic milieu in an inpatient setting. Choice D, home visits, would typically occur post-discharge and focus on community reintegration, rather than maintaining a therapeutic milieu within the inpatient setting.

3. A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. What intervention is best for the nurse to implement?

Correct answer: D

Rationale: The best intervention for a male client with schizophrenia displaying echolalia, which is disruptive to others, is for the nurse to escort the client to his room. Echolalia, the constant repetition of others' words, can be disruptive in a communal setting. By guiding the client to a private space like his room, the nurse helps manage the behavior without isolating or medicating the client unnecessarily. Avoiding acknowledging the behavior (Choice A) does not address the issue, isolating the client (Choice B) may exacerbate feelings of exclusion, and administering a PRN sedative (Choice C) should be reserved for situations where there is imminent risk or severe agitation, not for managing echolalia.

4. 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?

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.

5. A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The RN also determines that the client is homeless and is exhibiting suspiciousness. The client’s plan of care should include what priority problem?

Correct answer: A

Rationale: Acute confusion is the priority problem because it directly impacts the client's safety and functioning. In this scenario, the client is disoriented, disorganized, and confused, which can pose immediate risks to her well-being. Ineffective community coping, disturbed sensory perception, and self-care deficit are not as urgent in this situation. Ineffective community coping focuses on the client's ability to manage stress related to the community, disturbed sensory perception pertains to alterations in sensory input, and self-care deficit involves the inability to perform activities of daily living independently. While these issues may also need addressing, acute confusion takes precedence due to the immediate safety concerns it presents.

Similar Questions

A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The RN also determines that the client is homeless and is exhibiting suspiciousness. The client’s plan of care should include what priority problem?
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, “I am the boss here. I do what I want.” Which nursing problem best supports these observations?
A client with schizophrenia explains that she has 20 children and then very seriously points to the nurse and explains that she is one of them. What is the most therapeutic response for the nurse to provide?
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 client with an eating disorder tells the RN, 'I’ve been eating only 400 calories per day and have been taking diuretics to lose weight.' What is the RN’s best response?
A male client with schizophrenia tells the RN that he is being watched and that the television is speaking directly to him. Which response by the RN is appropriate?
ATI TEAS 7 Exam Overview

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