HESI RN
Mental Health HESI
1. A client is being educated by a healthcare professional about initiating a prescribed abstinence therapy using Disulfiram (Antabuse). What information should the client acknowledge understanding?
- A. Admit to others that they are a substance abuser.
- B. Remain alcohol-free for 12 hours before taking the first dose.
- C. Attend monthly Alcoholics Anonymous meetings.
- D. Completely abstain from heroin or cocaine use.
Correct answer: B
Rationale: B: Before starting Disulfiram therapy, it is crucial for clients to be alcohol-free for a minimum of 12 hours to prevent adverse reactions. A: Admitting substance abuse is important, but it is not directly linked to the initiation of Disulfiram therapy. C: Attending Alcoholics Anonymous meetings is beneficial for support but not a specific requirement for starting Disulfiram. D: The focus of Disulfiram therapy is on alcohol abstinence, so abstaining from heroin or cocaine is not directly related to this medication.
2. An elderly client diagnosed with delirium is being treated with antipsychotic medication. Which side effect should the nurse monitor for in this client?
- A. Akathisia
- B. Hallucinations
- C. Orthostatic hypotension
- D. Drowsiness
Correct answer: C
Rationale: The correct side effect that the nurse should monitor for in an elderly client diagnosed with delirium and treated with antipsychotic medication is orthostatic hypotension. Antipsychotic medications can lead to a drop in blood pressure upon standing, particularly in elderly individuals. Akathisia (choice A) refers to a movement disorder characterized by a feeling of inner restlessness and a compelling need to be in constant motion, which can be a side effect of antipsychotic medications but is not specific to elderly clients with delirium. Hallucinations (choice B) are sensory perceptions that appear real but are created by the mind, and while they can be associated with certain conditions or medications, they are not a common side effect of antipsychotic medications in elderly clients with delirium. Drowsiness (choice D) is a general CNS depressant effect that can occur with antipsychotic medications but is not the specific side effect that the nurse should be monitoring for in this case.
3. A client with a history of substance abuse is admitted to the hospital for treatment of a new illness. Which of the following is the most important to assess upon admission?
- A. History of recent drug use.
- B. Current employment status.
- C. Family history of mental illness.
- D. Recent weight changes.
Correct answer: A
Rationale: Assessing the history of recent drug use is crucial when admitting a client with a history of substance abuse. Understanding recent drug use helps in managing potential withdrawal symptoms, preventing drug interactions with the new treatment, and ensuring appropriate care. Assessing current employment status (choice B) is important for social and financial support but is not as crucial as assessing recent drug use in this scenario. Family history of mental illness (choice C) and recent weight changes (choice D) are also important aspects of assessment but are not as immediate and critical as evaluating recent drug use in a client with a history of substance abuse.
4. The nurse accepts a transfer to the mental health unit and understands that the client is distractible and is exhibiting a decreased ability to concentrate. The nurse has only 15 minutes to talk with the client. To develop a treatment plan for this client, which assessment is most important for the nurse to obtain?
- A. Motivation for treatment
- B. History of substance use
- C. Medication compliance
- D. Mental status examination
Correct answer: D
Rationale: A mental status examination is the most important assessment for the nurse to obtain in this scenario. It provides a comprehensive view of the client's current cognitive functioning, including their level of alertness, orientation, memory, attention, and thought process. Understanding the client's mental status is crucial for developing an appropriate treatment plan. The other options, such as motivation for treatment, history of substance use, and medication compliance, are important aspects to consider but may not directly address the client's current cognitive state and immediate treatment needs as effectively as a mental status examination.
5. A male adult is admitted because of an acetaminophen (Tylenol) overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client’s discharge plan?
- A. Eat a high-carbohydrate, low-fat, low-protein diet.
- B. Do not take any over-the-counter medication.
- C. Call the crisis hotline if feeling lonely.
- D. Avoid exposure to large crowds.
Correct answer: B
Rationale: The most important information for the nurse to include in the client’s discharge plan is to not take any over-the-counter medication. This is crucial because over-the-counter medications can potentially interact with the damaged liver and worsen the condition. Choices A, C, and D are not as critical in the context of liver damage from an acetaminophen overdose. While diet is important for overall health, specifically for liver damage, avoiding over-the-counter medications takes precedence. Calling the crisis hotline for loneliness and avoiding exposure to large crowds are important considerations but are not directly related to the client's liver damage from the acetaminophen overdose.
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