a nurse is assessing a client with post traumatic stress disorder ptsd who reports having frequent nightmares what is the nurses best response
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Nursing Elites

HESI LPN

Mental Health HESI 2023

1. A client with post-traumatic stress disorder (PTSD) reports having frequent nightmares. What is the nurse's best response?

Correct answer: C

Rationale: The best response for the nurse is to discuss relaxation techniques with the client that can help reduce anxiety and stress before bedtime. This approach may potentially decrease the frequency of nightmares by promoting a more calming and peaceful pre-sleep routine. Choice A is incorrect because while nightmares can be common with PTSD, it is not guaranteed that they will decrease over time. Choice B is incorrect as avoiding thinking about the trauma may not address the underlying issue causing the nightmares. Choice D is incorrect as prescribing a sleep aid should be considered as a last resort after trying non-pharmacological interventions.

2. A female client with anorexia nervosa is admitted to the hospital. What is the priority assessment for the nurse to perform?

Correct answer: B

Rationale: The correct answer is to monitor the client's electrolyte levels. In clients with anorexia nervosa, electrolyte imbalances can lead to serious, potentially life-threatening complications such as cardiac arrhythmias. Assessing body image perception (choice A) is important but not the priority when compared to monitoring electrolyte levels. Evaluating exercise habits (choice C) and assessing the client's relationship with her family (choice D) are also important aspects of care but do not take precedence over monitoring electrolyte levels in a client with anorexia nervosa.

3. In observing a client who is pacing, agitated, and presenting aggressive gestures, with rapid speech pattern and belligerent affect, what is the immediate priority of care for the nurse?

Correct answer: A

Rationale: In a situation where a client is displaying aggression and agitation, the immediate priority of care for the nurse is to ensure safety for the client and others on the unit. Providing a safe environment and implementing calming measures take precedence over other interventions. Option A is the correct choice as it addresses the crucial need for safety in a potentially volatile situation. Options B, C, and D, although important, do not address the primary concern of ensuring safety for all individuals involved.

4. A 20-year-old female client with schizophrenia is scheduled to receive risperidone (Risperdal) 2mg at bedtime. When the nurse attempts to administer the medication, the client states, 'I am not going to take that medicine, and you can't make me.' What action should the nurse take?

Correct answer: D

Rationale: In this scenario, the correct action for the nurse to take is to respect the client's autonomy and decision-making capacity. It's crucial to document the medication refusal accurately in the client's record. Administering the medication via a nasogastric tube or substituting it with an injectable form would violate the client's right to refuse treatment and should only be considered in extreme cases after consulting with the healthcare team. Encouraging the client to take the medication because it will help her sleep disregards her autonomy and choice in the matter.

5. A client with bipolar disorder, manic phase, is admitted to the psychiatric unit. Which meal is most appropriate for this client?

Correct answer: B

Rationale: A chicken salad sandwich (B) is the most appropriate choice as it is easy to eat on the go, which is important for a client in the manic phase who may have difficulty sitting still for a meal. Spaghetti and meatballs (A) and steak and potatoes (C) require more time and effort to eat, which may be challenging for a client experiencing mania. While hamburger and fries (D) could be an option, a chicken salad sandwich is a healthier and more manageable choice, considering the client's potential hyperactive state.

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