HESI RN
Quizlet Mental Health HESI
1. A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit’s day room. What action should the nurse implement first?
- A. Administer a PRN sedative.
- B. Sit in the chair next to the client.
- C. Escort the client to his room.
- D. Listen to what the client is saying.
Correct answer: D
Rationale: When dealing with a client experiencing auditory hallucinations, it is crucial for the nurse to first listen to what the client is saying. Auditory hallucinations may hold significance to the client, and by actively listening, the nurse can gather information about the content and context of the hallucinations. This information helps the nurse assess the client's current state, emotional responses, and the potential triggers for the behavior. Administering a PRN sedative (Choice A) should not be the initial action as it may suppress important information and feelings the client is trying to communicate. Sitting next to the client (Choice B) may not be appropriate without understanding the situation better. Escorting the client to his room (Choice C) may escalate the situation without addressing the underlying cause of the behavior, which can be better understood through active listening.
2. The RN is admitting a male client who takes lithium carbonate (Eskalith) twice a day. Which information should the RN report to the HCP immediately?
- A. Short-term memory loss.
- B. Five-pound weight gain.
- C. Decreased affect.
- D. Nausea and vomiting.
Correct answer: D
Rationale: Nausea and vomiting are signs of potential lithium toxicity, which is a serious condition requiring immediate attention. These symptoms can indicate a dangerous level of lithium in the body that can lead to severe complications. Short-term memory loss (A), five-pound weight gain (B), and decreased affect (C) are important to monitor but are not as immediately concerning as symptoms of potential toxicity like nausea and vomiting.
3. A client with obsessive-compulsive disorder (OCD) is receiving a new prescription for fluoxetine (Prozac). Which statement by the client indicates an understanding of this medication?
- A. “I should begin feeling less anxious within a few weeks.”
- B. “The drug will help me control my compulsive behaviors.”
- C. “I will need to have a weekly blood test to check my liver function.”
- D. “I should avoid foods that contain tyramine while taking this medication.”
Correct answer: B
Rationale: The correct answer is B. Fluoxetine, an SSRI, can help manage symptoms of OCD by assisting in controlling compulsive behaviors rather than directly reducing anxiety. The improvement in symptoms usually occurs over a few weeks. Choice A is incorrect as it provides a timeframe for anxiety improvement, which is not the primary goal of fluoxetine in OCD treatment. Choice C is incorrect as routine blood tests are not typically required with fluoxetine. Choice D is incorrect as avoiding tyramine-containing foods is more relevant for MAOIs, not SSRIs like fluoxetine.
4. A female client requests that her husband be allowed to stay in the room during the admission assessment. While interviewing the client, the nurse notes a discrepancy between the client’s verbal and nonverbal communication. What action should the nurse take?
- A. Pay close attention and document the nonverbal messages.
- B. Ask the client’s husband to interpret the discrepancy.
- C. Ignore the nonverbal behavior and focus on the client’s verbal messages.
- D. Integrate the verbal and nonverbal messages and interpret them as one.
Correct answer: A
Rationale: When a nurse observes a discrepancy between a client's verbal and nonverbal communication, it is essential to pay close attention and document the nonverbal messages. Nonverbal cues, such as body language and facial expressions, can provide valuable insights into the client's emotional state, feelings, and concerns that may not be expressed verbally. By documenting these nonverbal messages, the nurse can gain a more comprehensive understanding of the client's communication and address any potential underlying issues. Asking the client's husband to interpret the discrepancy (Choice B) may not always provide an accurate understanding of the client's nonverbal cues. Ignoring the nonverbal behavior (Choice C) could lead to missing important cues affecting the client's care. Integrating verbal and nonverbal messages (Choice D) is important, but initially focusing on documenting and understanding the nonverbal cues can enhance the nurse's assessment and communication with the client.
5. In pediatric mental health, there is a lack of sufficient numbers of community-based resources and providers, resulting in long waiting lists for services. This has resulted in:
- A. Children of color and those in poor economic conditions being underserved
- B. Increased stress in the family unit
- C. Markedly increased funding
- D. Premature termination of services
Correct answer: D
Rationale: The correct answer is D, 'Premature termination of services.' The lack of sufficient numbers of community-based resources and providers, along with long waiting lists, can lead to premature termination of services for children in need of mental health support. Choice A, 'Children of color and those in poor economic conditions being underserved,' is not directly related to the consequence mentioned in the question. Choice B, 'Increased stress in the family unit,' while a potential consequence, is not explicitly stated in the question as a direct result of the lack of resources. Choice C, 'Markedly increased funding,' is not a consequence but rather a potential solution to address the lack of resources.
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