HESI RN
Quizlet HESI Mental Health
1. A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. What intervention is best for the RN to implement?
- A. Isolate the client from the other clients.
- B. Administer a PRN sedative.
- C. Avoid recognizing the behavior.
- D. Escort the client to his room.
Correct answer: C
Rationale: The correct intervention for the RN to implement in this situation is to avoid recognizing the behavior. By not reinforcing the echolalia through recognition, the behavior is less likely to be perpetuated, and it can reduce annoyance to other clients on the unit. Isolating the client may lead to feelings of rejection and exacerbate the behavior. Administering a PRN sedative should not be the first line of intervention for echolalia, as it does not address the underlying cause. Escorting the client to his room does not actively address the behavior or provide a therapeutic response.
2. A male client comes to the emergency center with an erection that will not resolve. The client reports that he is taking trazodone (Desyrel) for insomnia. Which information is most important for the nurse to ask this client?
- A. Have you taken any medication for erectile dysfunction?
- B. Are you experiencing any other sexual dysfunctions or problems?
- C. When was the last time you consumed alcohol?
- D. Do you have a history of angina or high blood pressure?
Correct answer: B
Rationale: In this scenario, the most important question for the nurse to ask the client is whether he is experiencing any other sexual dysfunctions or problems. This inquiry is crucial as it can help in determining if the persistent erection is a side effect of trazodone. Asking about medication for erectile dysfunction (Choice A) may not provide relevant information in this case, as the focus is on the potential side effects of trazodone. Inquiring about the last time the client consumed alcohol (Choice C) is not directly related to the situation at hand. Questioning about a history of angina or high blood pressure (Choice D) is important for overall assessment but is not as directly relevant to the immediate concern of the persistent erection potentially caused by trazodone.
3. The RN documents the mental status of a female client who has been hospitalized for several days by court order. The client states, “I don’t need to be here,†and tells the RN that she believes that the TV talks to her. The RN should document these assessment statements in which section of the mental status exam?
- A. Insight and judgment.
- B. Mood and affect.
- C. Remote memory.
- D. Level of concentration.
Correct answer: A
Rationale: The client's statement of not needing to be hospitalized and her belief that the TV talks to her indicate impaired insight and judgment. Insight and judgment evaluate the client's awareness of their condition and ability to make sound decisions. Mood and affect assess emotional state, remote memory evaluates recall of past events, and level of concentration assesses attention and focus. In this scenario, the client's lack of awareness of her need for hospitalization and presence of delusions about the TV speaking to her directly relate to insight and judgment, making choice A the correct option.
4. A female client engages in repeated checks of door and window locks, a behavior that prevents her from arriving on time and interferes with her ability to function effectively. What action should the nurse take?
- A. Ask the client why she checks the locks.
- B. Discuss checking the time frequently.
- C. Determine the type and size of the locks.
- D. Plan a list of activities to be carried out daily.
Correct answer: D
Rationale: Planning a list of daily activities can help the client manage her time better and reduce the impact of her compulsive behaviors. This structured approach can assist the client in organizing her day, potentially reducing the need for excessive lock checking. Option A is incorrect because simply asking why the client checks the locks may not address the underlying issue effectively. Option B is not relevant to the compulsive behavior of checking locks and does not offer a practical solution. Option C does not directly address the client's compulsive behavior but focuses on the physical attributes of the locks, which is not the primary concern in this scenario.
5. A client with major depressive disorder is prescribed lithium carbonate. Which finding should the RN report to the healthcare provider?
- A. Serum lithium level of 0.8 mEq/L
- B. Blood urea nitrogen (BUN) level of 16 mg/dL
- C. Serum sodium level of 138 mEq/L
- D. Urine output of 800 mL in 24 hours
Correct answer: B
Rationale: The correct answer is B. Elevated BUN levels may indicate renal impairment, which is crucial to report for clients on lithium due to its potential kidney effects. Option A, a serum lithium level of 0.8 mEq/L, is within the therapeutic range for lithium and does not require immediate reporting. Option C, a serum sodium level of 138 mEq/L, is within the normal range and not directly related to lithium therapy. Option D, urine output of 800 mL in 24 hours, may indicate a need for further assessment but is not the most critical finding to report compared to potential renal impairment indicated by an elevated BUN level.
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