the nurse is planning discharge for a male client with schizophrenia the client insists that he is returning to his apartment although the healthcare
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Nursing Elites

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Mental Health HESI Practice Questions

1. The client is planning discharge for a male client with schizophrenia. The client insists that he is returning to his apartment, although the healthcare provider informed him that he will be moving to a boarding home. What is the most important nursing diagnosis for discharge planning?

Correct answer: A

Rationale: The best nursing diagnosis is (A) because the client is unable to acknowledge the move to a boarding home. While (B, C, and D) are potential nursing diagnoses, denial is the most critical as it is a defense mechanism preventing the client from addressing his feelings regarding the change in living arrangements.

2. A client with borderline personality disorder tells the nurse, 'You're the only one who understands me. The other nurses don't care about me.' Which response by the nurse is most appropriate?

Correct answer: C

Rationale: The most appropriate response is 'I am here to help you just like the other nurses' (C). This response sets boundaries and avoids reinforcing the client's splitting behavior, which is common in borderline personality disorder. Choices A and D may unintentionally reinforce the splitting by focusing on the negative perception of other nurses. Choice B might be perceived as dismissive because it contradicts the client's feelings of being understood only by the nurse.

3. The nurse should hold the next scheduled dose of a client's haloperidol (Haldol) based on which assessment finding(s)?

Correct answer: D

Rationale: A fever (D) may indicate neuroleptic malignant syndrome (NMS), a potentially fatal complication of antipsychotics. The healthcare provider should be contacted before administering the next dose of Haldol. Dizziness when standing (A), shuffling gait and hand tremors (B), and urinary retention (C) are all adverse effects of Haldol that, while concerning, do not pose immediate life-threatening risks compared to the potential severity of NMS indicated by a fever.

4. A client is scheduled to complete a positron emission tomography (PET) scan. The client asks the nurse to explain the reason the test was prescribed. How should the nurse respond?

Correct answer: C

Rationale: The correct answer is C. PET scans are primarily used to detect and observe the metabolic activity in various parts of the brain. This helps in diagnosing conditions related to brain function, such as tumors, brain disorders, and overall brain activity. Choices A, B, and D are incorrect because PET scans focus on metabolic activity and functions in the brain rather than solely indicating the presence of tumors, outlining brain structures, or showing biochemical levels of neurotransmitters.

5. Which action should the nurse implement first for a client experiencing alcohol withdrawal?

Correct answer: D

Rationale: The correct action for the nurse to implement first for a client experiencing alcohol withdrawal is to prepare the environment to prevent self-injury. Clients undergoing alcohol withdrawal are at risk of seizures and other symptoms that may lead to self-harm. By ensuring a safe environment, the nurse can mitigate the risk of injury. Applying restraints (Choice A) should only be considered if less restrictive measures fail, as restraints can agitate the client further. Giving an alpha-adrenergic blocker (Choice B) may be part of the treatment plan for alcohol withdrawal but is not the first action to take. Providing a diet high in protein and calories (Choice C) is important for overall health but is not the priority when addressing immediate safety concerns.

Similar Questions

A client with anorexia nervosa is being treated in an inpatient unit. Which intervention is a priority for the nurse?
A client on the psychiatric unit appears to imitate a certain nurse on the unit. The client seeks out this particular nurse and imitates the nurse's mannerisms. The nurse knows that the client is using which defense mechanism?
A client with obsessive-compulsive disorder (OCD) spends hours each day washing their hands. Which nursing intervention is most appropriate initially?
A client with major depressive disorder is prescribed an SSRI. After one week, the client reports feeling no improvement in mood. What is the best response by the RN?
A client with bipolar disorder is being discharged with a prescription for lithium. What is the most important instruction the nurse should provide?

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