HESI RN
Mental Health HESI Quizlet
1. A client who is admitted with a closed head injury after a fall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the nurse identify as the priority?
- A. Place in a side-lying position with head of bed elevated.
- B. Administer disulfiram (Antabuse) immediately
- C. Give lorazepam (Ativan) PRN for signs of withdrawal.
- D. Provide thiamine and folate supplements as prescribed.
Correct answer: A
Rationale: Maintain the patient's airway is the priority for a client who is intoxicated and obtunded.
2. A client with schizophrenia is exhibiting visual and auditory hallucinations. What should be the RN’s initial intervention?
- A. Instruct the client to ignore the hallucinations.
- B. Encourage the client to describe the hallucinations in detail.
- C. Assess the client’s perception of the hallucinations.
- D. Provide reassurance that the hallucinations are not real.
Correct answer: C
Rationale: The correct initial intervention for a client with schizophrenia exhibiting visual and auditory hallucinations is to assess the client’s perception of the hallucinations. This step is crucial as it helps the RN determine the severity of the hallucinations and the best course of action for management and intervention. Instructing the client to ignore the hallucinations (Choice A) may not be effective as the hallucinations may be distressing and overwhelming. Encouraging the client to describe the hallucinations in detail (Choice B) may potentially worsen the symptoms or trigger further distress. Providing reassurance that the hallucinations are not real (Choice D) may not be appropriate as the client may genuinely believe in their reality, and this reassurance may not address the underlying issues causing the hallucinations.
3. A male client approaches the nurse with an angry expression on his face and raises his voice, saying, “My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out!” The nurse recognizes that the client is using which defense mechanism?
- A. Denial
- B. Projection
- C. Rationalization
- D. Splitting
Correct answer: B
Rationale: The correct answer is B: Projection. In this scenario, the client is projecting his own feelings of anger onto his roommate by attributing his anger to the roommate. Projection involves shifting one's feelings, thoughts, or impulses onto another person. Denial (choice A) is the refusal to accept reality, Rationalization (choice C) involves justifying behaviors with logical reasons, and Splitting (choice D) is the inability to integrate positive and negative qualities of oneself or others.
4. A client on the mental health unit is becoming more agitated, shouting at the staff, and pacing in the hallway. When a PRN medication is offered, the client refuses the medication and defiantly sits on the floor in the middle of the unit hallway. What nursing intervention should the nurse implement first?
- A. Transport the client to the seclusion room.
- B. Quietly approach the client with additional staff members.
- C. Take other clients in the area to the client lounge.
- D. Administer medication to chemically restrain the client.
Correct answer: B
Rationale: In situations where a client is agitated and refusing medication, a non-confrontational approach with additional staff can help de-escalate the situation and address the client's behavior safely. Transporting the client to the seclusion room (Choice A) should not be the initial intervention unless the client poses an immediate risk of harm to themselves or others. Taking other clients to the client lounge (Choice C) does not directly address the agitated client's behavior. Administering medication to chemically restrain the client (Choice D) should only be considered after other de-escalation attempts have been made and if there is a significant safety concern.
5. While interviewing a client, the nurse takes notes to assist with accurate documentation later. Which statement is most accurate regarding note-taking during an interview?
- A. The client’s comfort level is increased when the nurse maintains eye contact while taking notes.
- B. The interview process is enhanced with note-taking, allowing the client to speak at a normal pace.
- C. Note-taking during an interview is not a legal obligation of the examining nurse.
- D. The nurse’s ability to directly observe the client’s nonverbal communication is limited with note-taking.
Correct answer: D
Rationale: During an interview, note-taking can hinder the nurse’s ability to directly observe the client's nonverbal cues such as body language, facial expressions, and tone of voice. These nonverbal cues are crucial for understanding the client's emotions, feelings, and overall communication. Therefore, it is essential for the nurse to strike a balance between note-taking for documentation purposes and actively observing the client's nonverbal communication to ensure a comprehensive assessment. Choices A, B, and C are incorrect because maintaining eye contact, enhancing the interview process with note-taking, and legal obligations of note-taking during an interview do not directly address the issue of limited observation of nonverbal communication while taking notes.
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