the rn is working with a male client at a community mental health center when the client reports hearing voices that tell him to get a knife from the
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Nursing Elites

HESI RN

Quizlet HESI Mental Health

1. While working with a male client at a community mental health center, the client reports hearing voices that tell him to get a knife from the kitchen and hurt himself. What intervention is most important for the RN to implement?

Correct answer: A

Rationale: The most crucial intervention for the RN to implement in this scenario is to prevent the client from accessing the kitchen where potential means of self-harm are available until the hallucination subsides. This immediate action is necessary to ensure the client's safety. While reporting the behavior to the client's case worker for further support is important, addressing the immediate risk of harm takes precedence. Assigning a UAP to stay with the client continually is valuable for ongoing monitoring but is secondary to ensuring immediate safety. Documenting the behavior in the client's record and notifying the healthcare provider are essential steps in the care process; however, they should follow actions taken to ensure the client's immediate safety.

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. An elderly client is admitted to the psychiatric unit with a diagnosis of major depressive disorder. Which assessment finding is most concerning for the nurse?

Correct answer: C

Rationale: In an elderly client with major depressive disorder, disorganized speech and thought processes are the most concerning assessment findings for the nurse. These symptoms can suggest a more severe condition such as psychosis or cognitive impairment, which require immediate attention and intervention. While weight loss, lack of interest in activities, severe fatigue, and low energy levels are common symptoms of major depressive disorder, they do not pose an immediate risk as disorganized speech and thought processes do. Therefore, the nurse should prioritize addressing the disorganized speech and thought processes to ensure the safety and well-being of the client.

4. 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?

Correct answer: B

Rationale: Encouraging the client to suck on hard candy is the appropriate intervention in this situation. Excessive thirst is a common side effect of lithium therapy. Sucking on hard candy can help alleviate the symptom without posing any harm. Reporting the client's serum lithium level to the healthcare provider (Choice A) is not necessary at this point as the symptom of excessive thirst is a known side effect and does not indicate toxicity. No action is needed (Choice C) is incorrect because addressing the client's distress is essential. Telling the client that drinking from the faucet is not allowed (Choice D) does not address the underlying issue of excessive thirst and may cause further distress to the client.

5. Carolina is surprised when her patient does not show for a regularly scheduled appointment. When contacted, the patient states, 'I don't need to come see you anymore. I have found a therapy app on my phone that I love.' How should Carolina respond to this news?

Correct answer: A

Rationale: Carolina should respond with choice A as it shows interest and willingness to understand the patient's new approach. By asking the patient to show the app, Carolina demonstrates openness to exploring the patient's perspective and the technology they find helpful. Choice B is incorrect as it appears dismissive, failing to acknowledge the patient's autonomy in choosing an alternative therapy method. Choice C is also inappropriate as it undermines the patient's decision-making and progress achieved so far. Choice D comes off as confrontational and judgmental, which could lead to the patient feeling defensive and less likely to engage in a constructive conversation.

Similar Questions

A female client, who is wearing dirty clothes and has a foul body odor, comes to the clinic reporting feeling scared because she is being stalked. What should the nurse do first?
A client with an eating disorder tells the RN, 'I’ve been eating only 400 calories per day and have been taking diuretics to lose weight.' What is the RN’s best response?
A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words, and wanders into other clients' rooms. The nurse decides that the client needs constant observation based on which of these assessment findings?
A client who recently experienced the death of a significant other arrives at the mental health center. The client reports loss of interest in usual activities, expresses a wish to be with the deceased significant other, has been eating very little, and has not slept in several days. Which client statement is most important for the RN to explore at this time?
A client with depression remains in bed most of the day and declines activities. Which nursing problem has the greatest priority for this client?

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