a male client comes to the emergency center with an erection that will not resolve the client reports that he is taking trazodone desyrel for insomnia
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Nursing Elites

HESI RN

Quizlet HESI Mental Health

1. A male client comes to the emergency center with an erection that will not resolve. The client reports that he is taking trazodone (Desyrel) for insomnia. Which information is most important for the nurse to ask this client?

Correct answer: B

Rationale: In this scenario, the most important question for the nurse to ask the client is whether he is experiencing any other sexual dysfunctions or problems. This inquiry is crucial as it can help in determining if the persistent erection is a side effect of trazodone. Asking about medication for erectile dysfunction (Choice A) may not provide relevant information in this case, as the focus is on the potential side effects of trazodone. Inquiring about the last time the client consumed alcohol (Choice C) is not directly related to the situation at hand. Questioning about a history of angina or high blood pressure (Choice D) is important for overall assessment but is not as directly relevant to the immediate concern of the persistent erection potentially caused by trazodone.

2. 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?

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.

3. During an exacerbation of schizophrenia symptoms, which intervention should the nurse prioritize for a client with a history of schizophrenia?

Correct answer: D

Rationale: During an exacerbation of schizophrenia symptoms, the nurse should prioritize assessing for safety risks. This is critical because individuals with schizophrenia may experience heightened risks to themselves or others during this period. Encouraging adherence to the medication regimen (Choice A) is important but ensuring immediate safety takes precedence. Increasing social interactions with peers (Choice B) and providing a high-stimulation environment (Choice C) can potentially exacerbate symptoms and should be avoided during an exacerbation.

4. A client who has a history of bipolar disorder is recovering from a manic episode and is now experiencing depressive symptoms. Which action should the nurse take first?

Correct answer: A

Rationale: Assessing for suicidal ideation is the priority when a client with bipolar disorder is transitioning from a manic episode to a depressive phase. Suicidal ideation is a critical concern during depressive episodes, and ensuring the client's safety is the top priority. Providing a detailed schedule of daily activities (Choice B) may be helpful but is not the immediate priority over assessing for suicidal ideation. Discussing the importance of medication adherence (Choice C) and encouraging group therapy (Choice D) are essential components of care but are secondary to ensuring the client's safety in the context of potential suicidal ideation.

5. 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?

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.

Similar Questions

A client with depression remains in bed most of the day and declines activities. Which nursing problem has the greatest priority for this client?
A male client with schizophrenia is being discharged from the psychiatric unit after being stabilized with antipsychotic medications. What is the most important instruction to include in the discharge teaching?
Which statement made by a patient prescribed bupropion (Wellbutrin) demonstrates that the medication education the patient received was effective? Select all that apply.
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 healthcare professional is preparing to provide medication education to a client who has just been prescribed an antipsychotic medication. What should the healthcare professional include in the teaching plan?

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