during an admission assessment and interview which channels of information communication should the nurse be monitoring select all that apply
Logo

Nursing Elites

HESI RN

Quizlet Mental Health HESI

1. During an admission assessment and interview, which channels of information communication should the healthcare professional be monitoring? Select all that apply.

Correct answer: A

Rationale: During an admission assessment and interview, healthcare professionals should monitor auditory, visual, and non-verbal cues. Auditory communication involves listening to the patient's spoken words, tone of voice, and any other sounds they make. Visual communication includes observing the patient's facial expressions, body language, and gestures. Written communication, such as forms or notes, may also provide valuable information. Tactile communication pertains to touch, which is not typically utilized during an admission interview setting. While all channels of communication are important, in this context, auditory cues are particularly crucial for gathering verbal information during the assessment process, making choice A the correct answer. Visual cues and written information are also significant but may not be as critical as auditory cues during an interview. Tactile communication is generally not a primary channel used during a standard admission assessment and interview, hence it is not a key focus in this scenario.

2. A client is being treated with a tricyclic antidepressant (TCA). Which side effect should the nurse monitor for?

Correct answer: A

Rationale: The correct answer is A: Constipation and urinary retention. Tricyclic antidepressants (TCAs) are known to have anticholinergic side effects, which include constipation and urinary retention. These side effects occur due to the inhibition of cholinergic receptors, leading to decreased gastrointestinal motility and relaxation of the detrusor muscle in the bladder. Choices B, C, and D are incorrect because increased appetite, weight loss, sedation, blurred vision, insomnia, and dry mouth are not typically associated with the use of TCAs. Monitoring for constipation and urinary retention is essential to prevent complications and ensure the client's safety.

3. Which client statement suggests to the nurse that the client is using the defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit?

Correct answer: B

Rationale: The correct answer is B because the client is projecting their aggressive impulses onto an inanimate object, the wall, instead of accepting their own feelings. This statement reflects the defense mechanism of projection. Choice A is not projection; it is an explanation of why the client is there. Choice C indicates acceptance of the facility and does not involve projection. Choice D is a denial statement rather than projection.

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

Correct answer: C

Rationale: The correct answer is C: 'Refusal to address nutritional needs.' In this scenario, the client's refusal to eat and address their nutritional needs poses an immediate threat to their physical health. Without proper nutrition, the client is at risk of malnutrition and its associated complications. While addressing social isolation, low self-esteem, and loss of interest in diversional activities are important aspects of holistic care for a client with depression, ensuring proper nutrition takes precedence due to the critical impact it has on the client's physical well-being. Therefore, the priority is to address the client's refusal to eat and address their nutritional needs to prevent further deterioration of their health.

5. A client with post-traumatic stress disorder (PTSD) is struggling with flashbacks and nightmares. Which therapeutic approach should the nurse include in the care plan?

Correct answer: A

Rationale: Corrected Question: A client with post-traumatic stress disorder (PTSD) experiencing flashbacks and nightmares would benefit from cognitive-behavioral therapy (CBT) in the care plan. CBT is an evidence-based therapeutic approach that focuses on identifying and changing negative thought patterns and behaviors associated with PTSD symptoms. This helps the client learn coping strategies to manage distressing symptoms like flashbacks and nightmares.\nIncorrect Choices Rationale: B) Electroconvulsive therapy (ECT) is not indicated for PTSD and is typically used for severe depression that has not responded to other treatments. C) Medication management alone may not address the underlying cognitive and behavioral aspects of PTSD. D) Relaxation training and mindfulness can be helpful as adjunctive therapies but may not be as effective as CBT in specifically targeting and modifying PTSD symptoms.

Similar Questions

A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit’s day room. What action should the nurse implement first?
In pediatric mental health, there is a lack of sufficient numbers of community-based resources and providers, resulting in long waiting lists for services. This has resulted in:
A client who has agoraphobia (a fear of crowds) is beginning desensitization with the therapist, and the RN is reinforcing the process. Which intervention has the highest priority for this client’s plan of care?
A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone (Risperdal). When the client walks to the nurse’s station in a laterally contracted position, he states that something has made his body contort into a monster. What action should the nurse take?
A female client engages in repeated checks of door and window locks, behavior that prevents her from arriving on time and interferes with her ability to function effectively. What action should the nurse take?

Access More Features

HESI RN Basic
$89/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses