HESI RN
Quizlet HESI Mental Health
1. What intervention is best for the nurse to implement for a male client with schizophrenia who is demonstrating echolalia, which is becoming annoying to other clients on the unit?
- A. Avoid acknowledging the behavior.
- B. Isolate the client from other clients.
- C. Administer a PRN sedative.
- D. Escort the client to his room.
Correct answer: D
Rationale: Echolalia, the constant repetition of what others are saying, can be disruptive to the therapeutic environment. The most appropriate intervention is to escort the client to his room. This action provides the client with a private space where he can engage in the behavior without disturbing other clients. Avoiding acknowledgment of the behavior (Choice A) may not address the issue and could lead to increased annoyance among other clients. Isolating the client (Choice B) may have negative psychological effects and should be avoided unless absolutely necessary for safety concerns. Administering a PRN sedative (Choice C) should be considered only as a last resort and if other de-escalation techniques have been unsuccessful.
2. An antidepressant medication is prescribed for a client who reports sleeping only 4 hours in the past 2 days and weight loss of 9 lbs within the last month. Which client goal is most important to achieve within the first three days of treatment?
- A. Meet scheduled appointments with a dietitian.
- B. Sleep at least 6 hours a night.
- C. Understand the purpose of the medication regimen.
- D. Describe the reasons for hospitalization.
Correct answer: B
Rationale: The most important goal to achieve within the first three days of treatment is to ensure the client can sleep at least 6 hours a night. Adequate sleep is essential for stabilizing mood and improving overall functioning. Improving sleep patterns is crucial to address the reported sleep deficit and weight loss associated with depression. Choice A is not as urgent as improving sleep patterns. Choice C is important but not as immediate as addressing the sleep deficit. Choice D is unrelated to the immediate treatment goal of improving sleep and managing symptoms of depression.
3. A client with schizophrenia is being discharged home after an extended stay in a psychiatric hospital. Which statement by the client indicates that further teaching about medication management is needed?
- A. “I will take my medication only when I feel like it.”
- B. “I need to follow up with my psychiatrist regularly.”
- C. “I will notify my healthcare provider if I experience side effects.”
- D. “I should avoid alcohol while on my medication.”
Correct answer: A
Rationale: The correct answer is A. This statement indicates a lack of understanding about medication management for schizophrenia. Medications for schizophrenia should be taken consistently as prescribed for optimal effectiveness, regardless of how the client feels. Choice B is a correct statement as regular follow-up with a psychiatrist is important for monitoring progress and adjusting treatment. Choice C demonstrates good awareness of potential side effects and the need for communication with healthcare providers. Choice D reflects appropriate knowledge as alcohol can interact with medications and may reduce their effectiveness.
4. Which client statement suggests to the nurse that the client is using the defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit?
- A. I am here because the police thought I was doing something wrong
- B. At least I hit the wall instead of hitting the psychiatric aide
- C. I want to be here because I know it is the best psychiatric facility
- D. Don’t believe everything my family tells you, I am not crazy
Correct answer: B
Rationale: The correct answer is B because the client is projecting their aggressive impulses onto an inanimate object, the wall, instead of accepting their own feelings. This statement reflects the defense mechanism of projection. Choice A is not projection; it is an explanation of why the client is there. Choice C indicates acceptance of the facility and does not involve projection. Choice D is a denial statement rather than projection.
5. 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.
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