a woman brings her 48 year old husband to the outpatient psychiatric unit and describes his behavior to the admitting nurse she states that he has bee
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HESI RN

Mental Health HESI Quizlet

1. A woman brings her 48-year-old husband to the outpatient psychiatric unit and describes his behavior to the admitting nurse. She states that he has been sleepwalking, cannot remember who he is, and exhibits multiple personalities. The nurse knows that these behaviors are often associated with:

Correct answer: C

Rationale: The correct answer is C: Dissociative identity disorder. Dissociative identity disorder (DID) is characterized by the presence of two or more distinct personality states or identities, along with memory gaps beyond ordinary forgetfulness. The description of the husband sleepwalking, not recognizing his identity, and exhibiting multiple personalities aligns with the symptoms of DID. Post-traumatic stress disorder (PTSD) (Choice A) involves re-experiencing traumatic events, panic disorder (Choice B) is characterized by recurrent panic attacks, and obsessive-compulsive disorder (OCD) (Choice D) involves obsessions and compulsions. These conditions do not typically present with the specific symptoms described in the scenario.

2. A client who is admitted to the mental health unit reports shortness of breath and dizziness. The client tells the nurse, “I feel like I’m going to die.” Which nursing problem should the nurse include in this client’s plan of care?

Correct answer: B

Rationale: The correct answer is B: Moderate anxiety. When a client presents with symptoms such as shortness of breath, dizziness, and a fear of dying, it indicates moderate anxiety. Anxiety can manifest physically with symptoms like these. Mood disturbance (choice A) refers to a change in mood, while altered thoughts (choice C) relate to cognitive changes. Social isolation (choice D) involves a lack of social interaction, which is not the primary concern in this scenario where the client is experiencing acute anxiety symptoms.

3. After receiving treatment for anorexia, a student asks the school nurse for permission to work in the school cafeteria as part of the school’s work-study program. What action should the nurse take?

Correct answer: A

Rationale: Clients with anorexia are often fixated on food and exercise, which can exacerbate their condition. By recommending assignment to the receptionist's office, the nurse provides an environment that minimizes exposure to food-related triggers. Working in the cafeteria may intensify the student's preoccupation with food, making it an unsuitable choice. Referring the student to a psychiatrist without exploring less triggering work options first may not be necessary. Determining the parents' opinion is important, but in this context, the focus should be on selecting a work environment that supports the student's recovery.

4. A mental health worker is caring for a client with escalating aggressive behavior. Which action by the mental health worker warrants immediate intervention by the RN?

Correct answer: A

Rationale: Attempting to physically restrain the client without proper protocol and preparation can escalate the situation. This can lead to increased agitation and aggression in the client, potentially putting both the client and the mental health worker at risk. Remaining at a distance, directing the client to a quiet area, or using a loud voice are all strategies that can be used to de-escalate the situation and ensure safety without resorting to physical intervention. Therefore, the immediate intervention is needed when the mental health worker attempts to physically restrain the client. Option B, remaining at a distance, is a safe practice to ensure personal safety. Option C, directing the client to a quiet area, is a de-escalation technique to create a calmer environment. Option D, using a loud voice, may be necessary to establish boundaries and ensure the client can hear instructions clearly.

5. A client on the mental health unit is becoming more agitated, shouting at the staff, and pacing in the hallway. When a PRN medication is offered, the client refuses the medication and defiantly sits on the floor in the middle of the unit hallway. What nursing intervention should the nurse implement first?

Correct answer: B

Rationale: In situations where a client is agitated and refusing medication, a non-confrontational approach with additional staff can help de-escalate the situation and address the client's behavior safely. Transporting the client to the seclusion room (Choice A) should not be the initial intervention unless the client poses an immediate risk of harm to themselves or others. Taking other clients to the client lounge (Choice C) does not directly address the agitated client's behavior. Administering medication to chemically restrain the client (Choice D) should only be considered after other de-escalation attempts have been made and if there is a significant safety concern.

Similar Questions

A client is admitted to the mental health unit and reports taking extra antianxiety medication because, “I’m so stressed out. I just wanted to go sleep.” The nurse should plan one-on-one observation of the client based on which statement?
A male client with bipolar disorder who began taking lithium carbonate five days ago is complaining of excessive thirst, and the RN finds him attempting to drink water from the bathroom sink faucet. Which intervention should the RN implement?
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?
The nurse on the day shift receives report about a client with depression who was found on the floor in the morning. What intervention is best for the nurse to implement?
A client with alcohol use disorder is being treated in a rehabilitation facility. Which behavior indicates that the client is making progress in recovery?

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