HESI RN
Quizlet Mental Health HESI
1. A male client with schizophrenia is admitted to the mental health unit after abruptly stopping his prescription for ziprasidone (Geodon) one month ago. Which question is most important for the nurse to ask the client?
- A. Have you lost interest in activities you used to enjoy?
- B. Has your ability to think or concentrate decreased?
- C. How many consecutive hours do you sleep at night?
- D. Do you hear sounds or voices that others do not hear?
Correct answer: D
Rationale: Inquiring about hallucinations is crucial for assessing the return of psychotic symptoms due to discontinuation of antipsychotic medication. Hearing sounds or voices that others do not hear can indicate the presence of auditory hallucinations, a common symptom in schizophrenia. Choices A, B, and C are important aspects to assess in clients with schizophrenia, but in this scenario, the priority is to determine if the client is experiencing hallucinations, which can be a sign of worsening psychotic symptoms.
2. A young adult male is hospitalized due to depression and an attempted suicide. The client reports that he lost his job and was angry with his employer for firing him when he took an overdose of pain medications. Which behavior best indicates to the nurse that his condition is improving?
- A. Initiates interactions with other clients.
- B. Describes verbally when he is angry.
- C. Participates in a job search with a social worker.
- D. Denies plans to harm himself or others.
Correct answer: A
Rationale: The best indicator of improvement in a client with depression is initiating interactions with others. This behavior demonstrates that the client is becoming less withdrawn and more self-directed, showing an improvement in social engagement and coping mechanisms. Choice B, describing anger verbally, may show some progress in emotional expression but does not necessarily indicate overall improvement in depression. Choice C, participating in a job search with a social worker, may be positive but does not directly address social interactions, which are crucial for improving depression. Choice D, denying plans to harm himself or others, is important for safety but does not directly reflect improvement in the client's social functioning or coping skills.
3. Kyle, a patient with schizophrenia, began taking the first-generation antipsychotic haloperidol (Haldol) last week. One day you find him sitting very stiffly and not moving. He is diaphoretic, and when you ask if he is okay, he seems unable to respond verbally. His vital signs are: BP 170/100, P 110, T 104.2°F. What is the priority nursing intervention? Select all that apply.
- A. Hold his medication and contact his prescriber.
- B. Wipe him with a washcloth wet with cold water or alcohol.
- C. Administer a medication such as benztropine IM to correct this dystonic reaction.
- D. Reassure him that although there is no treatment for his tardive dyskinesia, it will pass.
Correct answer: C
Rationale: The correct intervention is to administer a medication such as benztropine IM to correct this dystonic reaction. The presentation of stiffness, diaphoresis, inability to respond verbally, and vital sign changes suggest an acute dystonic reaction, which is an extrapyramidal side effect of antipsychotic medications like haloperidol. Benztropine is an anticholinergic medication commonly used to manage these acute dystonic reactions. Option A is incorrect because holding the medication without addressing the acute symptoms may lead to worsening of the condition. Option B is incorrect as wiping with cold water or alcohol does not address the underlying cause of the symptoms. Option D is incorrect because it mentions tardive dyskinesia, which is a different condition characterized by involuntary movements that occur with long-term antipsychotic use, not the acute dystonic reaction seen here.
4. A female client engages in repeated checks of door and window locks, behavior that prevents her from arriving on time and interferes with her ability to function effectively. What action should the nurse take?
- A. Discuss why the client checks the locks frequently
- B. Ask the client why she checks the locks
- C. Plan a daily list of activities to be carried out
- D. Determine the type and size of the locks
Correct answer: B
Rationale: The correct action for the nurse to take is to ask the client why she checks the locks. By doing so, the nurse can help the client gain insight into the underlying anxiety that drives this behavior and assist her in developing new adaptive coping strategies. Choice A is not as effective as directly asking the client about her behavior. Choice C focuses on planning activities but does not address the root cause of the client's behavior. Choice D is irrelevant to addressing the client's repeated checking behavior.
5. 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.
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