HESI RN
Quizlet HESI Mental Health
1. An elderly client is admitted to the psychiatric unit with a diagnosis of major depressive disorder. Which assessment finding is most concerning for the nurse?
- A. Weight loss of 5 pounds in one week.
- B. Lack of interest in previously enjoyed activities.
- C. Disorganized speech and thought processes.
- D. Severe fatigue and low energy levels.
Correct answer: C
Rationale: In an elderly client with major depressive disorder, disorganized speech and thought processes are the most concerning assessment findings for the nurse. These symptoms can suggest a more severe condition such as psychosis or cognitive impairment, which require immediate attention and intervention. While weight loss, lack of interest in activities, severe fatigue, and low energy levels are common symptoms of major depressive disorder, they do not pose an immediate risk as disorganized speech and thought processes do. Therefore, the nurse should prioritize addressing the disorganized speech and thought processes to ensure the safety and well-being of the client.
2. The RN is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? (SOA)
- A. Purchase a gun for protection.
- B. Establish a code with family and friends to signal violence.
- C. Take a self-defense course focused on protection.
- D. Prepare a bag with extra clothes for self and children.
Correct answer: B
Rationale: Establishing a code with family and friends is crucial in situations of intimate partner violence as it allows discreet communication for help without alerting the abuser. Having a pre-prepared bag with essentials like extra clothes is important to facilitate a quick exit if necessary. Purchasing a gun is not a recommended safety strategy as it can escalate violence and pose more danger. While taking a self-defense course focused on protection is beneficial, it is essential to avoid courses that emphasize retaliation, as they can increase the risk and escalate violence.
3. Which factors tend to increase the difficulty of diagnosing young children who demonstrate behaviors associated with mental illness? Select all that apply.
- A. Limited language skills
- B. Level of cognitive development
- C. Level of emotional development
- D. Parental denial that a problem exists
Correct answer: B
Rationale: The correct answer is B: Level of cognitive development. The level of cognitive development is a crucial factor that can complicate the diagnosis of mental illness in young children. Young children may not have fully developed cognitive abilities to express their symptoms or understand diagnostic procedures, making it challenging for healthcare providers to assess their mental health accurately. Limited language skills (choice A) can hinder communication but are not as significant as cognitive development in diagnosing mental illness. Emotional development (choice C) is important but may not be as directly linked to the diagnostic challenges as cognitive development. Parental denial (choice D), although a potential barrier, is not a factor inherent to the child's characteristics affecting the diagnostic process.
4. A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone (Risperdal). When the client walks to the nurse’s station in a literally contracted position, he states that something has made his body contort into a monster. What action should the nurse take?
- A. Medicate the client with the prescribed antipsychotic thioridazine (Mellaril).
- B. Offer the client a prescribed physical therapy hot pack for muscle spasms.
- C. Direct the client to occupational therapy to distract him from somatic complaints.
- D. Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia.
Correct answer: D
Rationale: The correct action for the nurse to take in this situation is to administer the prescribed anticholinergic benztropine (Cogentin) for dystonia. The client's symptoms of body contortion and feeling like a monster are indicative of acute dystonia, which can be a side effect of antipsychotic medications like risperidone. Benztropine can help alleviate these acute dystonic reactions. Choice A is incorrect because changing the antipsychotic medication at this point is not indicated. Choice B is not appropriate as the client's symptoms are likely due to acute dystonia rather than muscle spasms. Choice C is also not the best course of action as the client needs immediate intervention for the acute dystonic reaction.
5. 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.
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