a male client with bipolar disorder who began taking lithium carbonate five days ago is complaining of excessive thirst and the nurse finds him attemp
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Nursing Elites

HESI RN

Mental Health HESI

1. A male client with bipolar disorder who began taking lithium carbonate five days ago is complaining of excessive thirst, and the nurse finds him attempting to drink water from the bathroom sink faucet. Which intervention should the nurse implement?

Correct answer: B

Rationale: Encouraging the client to suck on hard candy is the appropriate intervention as it can help alleviate the sensation of excessive thirst, which is a common side effect of lithium. Reporting the client’s serum lithium level to the healthcare provider may be needed if there are signs of lithium toxicity, but the priority here is to address the immediate symptom of excessive thirst. Polydipsia, or excessive thirst, is a known side effect of lithium, but it should not be left unaddressed. Simply telling the client that drinking from the faucet is not allowed does not address the underlying issue of excessive thirst and may lead to further distress.

2. James is a 42-year-old patient with schizophrenia. He approaches you as you arrive for day shift and anxiously reports, 'Last night, demons came to my room and tried to rape me.' Which response would be most therapeutic?

Correct answer: C

Rationale: Choice C is the most therapeutic response as it acknowledges the patient's feelings and encourages further exploration of their experience. By expressing empathy and inviting James to share more about what he experienced, it helps build trust and rapport. Choices A and B dismiss the patient's experience and can make them feel invalidated, which is not helpful in establishing a therapeutic relationship. Choice D acknowledges the fear but does not actively engage the patient in discussing their feelings and experiences, missing an opportunity for therapeutic communication.

3. A young adult female visits the mental health clinic complaining of diarrhea, headache, and muscle aches. She is afebrile, denies chills, and all laboratory findings are within normal limits. During the physical assessment, the client tells the RN that her sister thinks she is neurotic and calls her a hypochondriac. Which response is best for the RN to provide?

Correct answer: B

Rationale: Acknowledging the impact of the sister's comments on the client helps validate the client's feelings and supports therapeutic dialogue.

4. A client with depression remains in bed most of the day and declines activities. Which nursing problem has the greatest priority for this client?

Correct answer: C

Rationale: The correct answer is C: 'Refusal to address nutritional needs.' When a client with depression remains in bed and declines activities, addressing their refusal to address nutritional needs is of utmost priority. Nutritional needs are essential for physical health and overall well-being. Inadequate nutrition can worsen the client's physical health, impact their mood, and hinder the effectiveness of treatment. Option A, 'Loss of interest in diversional activity,' while important, is not as critical as addressing nutritional needs for immediate physical well-being. Option B, 'Social isolation,' is a significant concern but addressing nutritional needs takes precedence due to its direct impact on physical health. Option D, 'Low self-esteem,' is a valid concern but does not take priority over addressing the client's refusal to meet their nutritional needs for immediate health benefits.

5. During an annual physical at a corporate clinic, a male employee tells the nurse that his high-stress job is causing trouble in his personal life. He further explains that he often gets so angry while driving to and from work that he has considered “getting even” with other drivers. How should the nurse respond?

Correct answer: B

Rationale: The correct response is to encourage the client to manage their anger and avoid impulsive actions, as stated in choice B. This approach helps the individual recognize the potential consequences of acting on their anger impulsively. Choice A is not the best response because it focuses on the contagious nature of anger rather than addressing the individual's behavior. Choice C is incorrect as it only highlights the potential dangers of expressing anger to a stranger without providing guidance on managing the underlying issue. Choice D acknowledges the client's feelings but does not offer practical advice on how to address the anger and potential impulsive actions.

Similar Questions

An elderly client is admitted to the psychiatric unit with a diagnosis of major depressive disorder. Which assessment finding is most concerning for the nurse?
A client with major depressive disorder is prescribed lithium carbonate. Which finding should the RN report to the healthcare provider?
A male client with schizophrenia tells the RN that he is being watched and that the television is speaking directly to him. Which response by the RN is appropriate?
A teenager who has lost 20 pounds in the last three months is admitted to the hospital with hypotension and tachycardia. The client reports irregular menses and hair loss. Which intervention is most important for the nurse to include in the client’s plan of care?
A client with anorexia nervosa has a body mass index (BMI) of 16.5 and has been diagnosed with bradycardia. Which of the following findings should the RN be most concerned about?

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