a male client with schizophrenia is demonstrating echolalia which is becoming annoying to other clients on the unit what intervention is best for the

HESI RN

Quizlet HESI Mental Health

1. A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. What intervention is best for the RN to implement?

A. Isolate the client from the other clients.
B. Administer a PRN sedative.
C. Avoid recognizing the behavior.
D. Escort the client to his room.

Correct answer: C

Rationale: The correct intervention for the RN to implement in this situation is to avoid recognizing the behavior. By not reinforcing the echolalia through recognition, the behavior is less likely to be perpetuated, and it can reduce annoyance to other clients on the unit. Isolating the client may lead to feelings of rejection and exacerbate the behavior. Administering a PRN sedative should not be the first line of intervention for echolalia, as it does not address the underlying cause. Escorting the client to his room does not actively address the behavior or provide a therapeutic response.

2. A client who recently experienced the death of a significant other arrives at the mental health center. The client reports loss of interest in usual activities, expresses a wish to be with the deceased significant other, has been eating very little, and has not slept in several days. Which client statement is most important for the RN to explore at this time?

A. Not sleeping for several days.
B. Wishing to be with the deceased significant other.
C. Lack of interest in usual activities.
D. Eating very little.

Correct answer: A

Rationale: The most important client statement for the RN to explore in this scenario is the client not sleeping for several days. The lack of sleep is a critical indicator of possible severe depression or suicidal ideation that requires immediate attention. While expressing a wish to be with the deceased significant other, having a lack of interest in usual activities, and eating very little are concerning, the immediate focus should be on the client's severe sleep disturbance as it can pose an immediate risk to their well-being and safety.

3. During the admission assessment of an underweight adolescent with depression on a psychiatric unit, the nurse finds a potassium level of 2.9 mEq/dl. Which finding requires notification to the healthcare provider?

A. Potassium level of 2.9 mEq/dl.
B. BP of 110/70 mmHg.
C. WBC of 10,000 mm³.
D. Body mass index of 21.

Correct answer: A

Rationale: A potassium level of 2.9 mEq/dl is critically low, indicating hypokalemia, which can lead to serious complications such as cardiac arrhythmias. Prompt notification to the healthcare provider is essential for immediate intervention. Choice B, a blood pressure of 110/70 mmHg, is within the normal range. Choice C, a white blood cell count of 10,000 mm³, is also within normal limits and is not a concerning finding in this context. Choice D, a body mass index of 21, may indicate being underweight but is not as urgent as addressing the critically low potassium level.

4. 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?

A. Level of concentration
B. Insight and judgment
C. Remote memory
D. Mood and affect

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.

5. Narcan was administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate (Vicodin). Within 15 minutes, the client is alert and oriented. In planning nursing care, which intervention has the highest priority at this time?

A. Encourage the client to increase fluid intake.
B. Obtain the client’s serum Vicodin level.
C. Observe the client for further narcotic effects.
D. Determine the client’s reason for attempting suicide.

Correct answer: C

Rationale: Observing the client for further narcotic effects is the priority at this time. It is crucial to monitor the client closely to prevent a relapse of symptoms or potential complications from the overdose. Encouraging fluid intake is important for overall health but not the priority after an overdose. Obtaining serum Vicodin levels may be needed later but does not address the immediate need to monitor for ongoing effects. Determining the reason for the suicide attempt is vital for psychological assessment but should come after ensuring the client's physical stability.