HESI RN
Quizlet Mental Health HESI
1. A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words, and wanders into other clients' rooms. The nurse decides that the client needs constant observation based on which of these assessment findings?
- A. Wanders into clients' rooms.
- B. Refuses antipsychotic medication.
- C. Talks with nonsensical words.
- D. Disrupts group activities.
Correct answer: D
Rationale: The correct answer is D. Disrupting group activities is a significant behavior that can pose risks to both the client and others. When combined with talking nonsensically and wandering into other clients' rooms, it indicates a need for constant observation to prevent harm or injury. Choices A, B, and C, although concerning, do not directly address the immediate safety concerns presented by disruptive behavior during group activities, which can lead to unpredictable situations and potential harm.
2. The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. What information should the nurse explore in-depth with the client based on this screening tool?
- A. Consumption, liver enzymes, gastrointestinal complaints, and bleeding.
- B. Minimizing drinking, frequently missing family events, guilt about drinking, and amount of daily intake.
- C. Cancer screening results, anger, gastritis, daily alcohol intake.
- D. Efforts to cut down, annoyance with questions, guilt, drinking as an “Eye-opener.â€
Correct answer: D
Rationale: The correct answer is D. The CAGE questionnaire is a screening tool for alcohol use disorder. Each letter in CAGE represents a key question: Cutting down, Annoyance by criticisms, Guilty feelings, and Eye-openers. These questions help assess problematic drinking behaviors and can provide valuable insights into the client's alcohol consumption habits. Choices A, B, and C do not directly align with the specific areas of inquiry covered by the CAGE questionnaire, making them incorrect. Therefore, the nurse should focus on exploring the client's efforts to cut down, annoyance with questions, feelings of guilt, and the use of alcohol as an “Eye-opener†based on this screening tool.
3. The healthcare provider 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 healthcare provider that she believes that the television talks to her. The healthcare provider should document these assessment findings in which section of the mental status exam?
- A. Level of concentration
- B. Insight and judgment
- C. Remote memory
- D. Mood and affect
Correct answer: B
Rationale: Insight and judgment should be documented as these findings assess the client’s awareness of their need for treatment and understanding of their condition. In this scenario, the client’s statement of not needing to be hospitalized and belief that the television talks to her reflect her insight into her situation and judgment regarding reality. The other options are incorrect: Level of concentration refers to the ability to focus and maintain attention; Remote memory evaluates the recall of past events and information; Mood and affect assess emotional state and expression, which are not directly reflected in the client's statements about her need for hospitalization and belief about the television.
4. An RN is providing education to the family of a client diagnosed with schizophrenia who is being treated with clozapine (Clozaril). The RN should instruct the family to report which symptom immediately?
- A. Sore throat
- B. Weight loss
- C. Constipation
- D. Lightheadedness
Correct answer: A
Rationale: The correct answer is A: Sore throat. Clozapine can lead to agranulocytosis, a condition characterized by a significant decrease in white blood cells. A sore throat can be an early sign of agranulocytosis, a potentially life-threatening adverse effect of clozapine. The family should report this symptom immediately to the healthcare provider for further evaluation and management. Choices B, C, and D are incorrect because weight loss, constipation, and lightheadedness are not typically associated with the serious adverse effect of agranulocytosis related to clozapine therapy.
5. A client who recently experienced the death of a significant other arrives at the mental health center. The client reports loss of interest in usual activities, expresses a wish to be with the deceased significant other, has been eating very little, and has not slept in several days. Which client statement is most important for the RN to explore at this time?
- A. Not sleeping for several days.
- B. Wishing to be with the deceased significant other.
- C. Lack of interest in usual activities.
- D. Eating very little.
Correct answer: A
Rationale: The most important client statement for the RN to explore in this scenario is the client not sleeping for several days. The lack of sleep is a critical indicator of possible severe depression or suicidal ideation that requires immediate attention. While expressing a wish to be with the deceased significant other, having a lack of interest in usual activities, and eating very little are concerning, the immediate focus should be on the client's severe sleep disturbance as it can pose an immediate risk to their well-being and safety.
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