HESI RN
Quizlet HESI Mental Health
1. A client is agitated and physically aggressive. What action should the RN take first?
- A. Calmly inform the client that they will be placed in seclusion if they do not calm down.
- B. Discuss with the client the reasons for their agitation and aggression.
- C. Tell the client that physical aggression is not acceptable and must stop.
- D. Seek assistance from other staff members and follow the facility’s protocol.
Correct answer: D
Rationale: In a situation where a client is agitated and physically aggressive, the priority for the RN is to ensure the safety of the client and others. Seeking assistance from other staff members is crucial as it allows for a prompt response to manage the situation effectively and according to the facility’s protocol. Choices A, B, and C do not address the immediate need for safety or involve the collaboration of other staff members, which is essential in handling aggressive behaviors in a healthcare setting.
2. The client is being educated by the healthcare provider about starting a prescribed abstinence therapy with disulfiram (Antabuse). What information should the client understand?
- A. Maintain complete abstinence from alcohol consumption.
- B. Stay alcohol-free for at least 12 hours before the first dose.
- C. Participate in monthly therapy sessions.
- D. Disclose to others that he is receiving disulfiram therapy.
Correct answer: B
Rationale: The correct answer is B. Before starting disulfiram therapy (Antabuse), the client must comprehend the need to remain alcohol-free for a minimum of 12 hours. This is crucial to prevent the unpleasant and potentially dangerous reactions that can occur with concurrent alcohol consumption while on disulfiram. Choice A is incorrect because it mentions heroin or cocaine use, which is not the primary focus when initiating disulfiram therapy. Choice C is incorrect as it suggests therapy sessions, which are not specifically required before starting disulfiram. Choice D is incorrect as there is no need to disclose disulfiram therapy to others, but rather to adhere to the abstinence requirement.
3. Narcan was administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate (Vicodin). Within 15 minutes, the client is alert and oriented. In planning nursing care, which intervention has the highest priority at this time?
- A. Encourage the client to increase fluid intake.
- B. Obtain the client’s serum Vicodin level.
- C. Observe the client for further narcotic effects.
- D. Determine the client’s reason for attempting suicide.
Correct answer: C
Rationale: Observing the client for further narcotic effects is the priority at this time. It is crucial to monitor the client closely to prevent a relapse of symptoms or potential complications from the overdose. Encouraging fluid intake is important for overall health but not the priority after an overdose. Obtaining serum Vicodin levels may be needed later but does not address the immediate need to monitor for ongoing effects. Determining the reason for the suicide attempt is vital for psychological assessment but should come after ensuring the client's physical stability.
4. A client in the emergency department presents with confusion, disorientation, and agitation after drinking alcohol. Which diagnostic test should the nurse anticipate to assess for potential complications?
- A. Complete blood count (CBC)
- B. Electrolyte panel
- C. Liver function tests
- D. Urinalysis
Correct answer: B
Rationale: The correct answer is an electrolyte panel. When a client presents with confusion, disorientation, and agitation after drinking alcohol, it indicates potential complications such as electrolyte imbalances. Monitoring electrolyte levels is crucial in these cases to detect and address abnormalities that may result from alcohol intake. While a complete blood count (choice A) may provide some valuable information, it is not the primary test to assess for alcohol-related complications presenting with these symptoms. Liver function tests (choice C) are more specific for assessing liver damage due to chronic alcohol use rather than immediate complications. Urinalysis (choice D) may help detect some issues but is not the most appropriate initial test to assess for potential complications in this scenario.
5. A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The nurse also determines that the client is homeless and slightly suspicious. This client’s treatment plan should include what priority problem?
- A. Self-care deficit.
- B. Disturbed sensory perception.
- C. Ineffective community coping.
- D. Acute confusion.
Correct answer: D
Rationale: The correct answer is 'D: Acute confusion.' In the given scenario, the client is disoriented, disorganized, and confused, indicating acute confusion. This is a priority issue to address for immediate safety and appropriate care. Option A, self-care deficit, is not the priority as the client's safety and mental status take precedence over self-care. Option B, disturbed sensory perception, is not applicable as the client's symptoms focus more on cognitive rather than sensory issues. Option C, ineffective community coping, is not the immediate concern as the client's cognitive state needs urgent attention to ensure her safety and well-being.
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