HESI RN
Quizlet Mental Health HESI
1. An older male client with schizophrenia is found smearing feces on the bathroom walls of the chronic mental health unit where he resides. What action should the RN implement?
- A. Explain that the feces belong in the toilet.
- B. Show the client how to clean the walls.
- C. Escort the client out of the bathroom.
- D. Assist the client to clean the walls.
Correct answer: C
Rationale: Escorting the client out of the bathroom is the most appropriate action to take in this situation. This helps prevent further inappropriate behavior and maintains hygiene, while avoiding reinforcement of the behavior. Option A, explaining that the feces belong in the toilet, may not be effective as the behavior is likely a manifestation of the client's condition rather than a lack of understanding. Option B, showing the client how to clean the walls, may not address the underlying issue and could potentially reinforce the behavior. Option D, assisting the client to clean the walls, may also reinforce the behavior and is not the best approach to managing the situation.
2. A client with major depressive disorder is beginning a new antidepressant medication. Which instruction should the nurse include in the discharge teaching?
- A. “It may take several weeks to notice improvement.â€
- B. “You should see immediate effects of the medication.â€
- C. “You can stop taking the medication once you feel better.â€
- D. “Avoid discussing your symptoms with your therapist.â€
Correct answer: A
Rationale: The correct instruction the nurse should include in the discharge teaching for a client starting a new antidepressant medication is that “It may take several weeks to notice improvement.†This is because antidepressants often require several weeks before the individual starts to feel the full therapeutic effects. Choice B is incorrect because immediate effects are not typically seen with antidepressants. Choice C is incorrect as stopping the medication abruptly can lead to worsening symptoms or withdrawal effects. Choice D is incorrect as open communication with the therapist is crucial for effective management of major depressive disorder.
3. A male client with bipolar disorder who began taking lithium carbonate five days ago is complaining of excessive thirst, and the RN finds him attempting to drink water from the bathroom sink faucet. Which intervention should the RN implement?
- A. Report the client’s serum lithium level to the healthcare provider (HCP).
- B. Encourage the client to suck on hard candy to relieve the symptoms.
- C. No action is needed since polydipsia is a common side effect.
- D. Tell the client that drinking from the faucet is not allowed.
Correct answer: B
Rationale: Encouraging the client to suck on hard candy is the appropriate intervention in this situation. Excessive thirst is a common side effect of lithium therapy. Sucking on hard candy can help alleviate the symptom without posing any harm. Reporting the client's serum lithium level to the healthcare provider (Choice A) is not necessary at this point as the symptom of excessive thirst is a known side effect and does not indicate toxicity. No action is needed (Choice C) is incorrect because addressing the client's distress is essential. Telling the client that drinking from the faucet is not allowed (Choice D) does not address the underlying issue of excessive thirst and may cause further distress to the client.
4. After surgery, a male client with antisocial personality disorder frequently requests a specific nurse be assigned to his care and becomes belligerent when another nurse is assigned. What action should the charge nurse implement?
- A. Reassure the client that his request will be met whenever possible.
- B. Advise the client that assignments are not based on client requests.
- C. Ask the client to explain why he constantly requests the nurse.
- D. Encourage the client to verbalize his feelings about the nurse.
Correct answer: B
Rationale: The correct action for the charge nurse is to advise the client that assignments are not based on client requests. Clients with antisocial personality disorder may attempt to manipulate situations to their advantage. By setting clear boundaries and explaining that assignments are not based on client preferences, the nurse helps prevent manipulation and maintains a professional approach to care. Reassuring the client about his requests (Choice A) may encourage the inappropriate behavior to continue. Asking the client to explain his requests (Choice C) may further fuel the manipulation by providing an opportunity for the client to justify his actions. Encouraging the client to verbalize feelings (Choice D) does not address the underlying issue of manipulating the assignment process and may inadvertently reinforce the behavior.
5. A male adult is admitted because of an acetaminophen (Tylenol) overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client’s discharge plan?
- A. Eat a high-carbohydrate, low-fat, low-protein diet.
- B. Do not take any over-the-counter medication.
- C. Call the crisis hotline if feeling lonely.
- D. Avoid exposure to large crowds.
Correct answer: B
Rationale: The most important information for the nurse to include in the client’s discharge plan is to not take any over-the-counter medication. This is crucial because over-the-counter medications can potentially interact with the damaged liver and worsen the condition. Choices A, C, and D are not as critical in the context of liver damage from an acetaminophen overdose. While diet is important for overall health, specifically for liver damage, avoiding over-the-counter medications takes precedence. Calling the crisis hotline for loneliness and avoiding exposure to large crowds are important considerations but are not directly related to the client's liver damage from the acetaminophen overdose.
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