when preparing to administer a prescribed medication to a homeless male at a community psychiatric clinic the client tells the nurse that he usually t
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Nursing Elites

HESI RN

Mental Health HESI

1. When preparing to administer a prescribed medication to a homeless male at a community psychiatric clinic, the client tells the nurse that he usually takes a different dosage. What action should the nurse take?

Correct answer: B

Rationale: Withholding the medication until the dosage can be confirmed ensures patient safety and accuracy in treatment.

2. During a group session on anger management, a male adolescent client is fidgety, interrupts peers, and talks about his pets at home. What action should the nurse take?

Correct answer: D

Rationale: The best nursing action in this scenario is to redirect the client by encouraging him to read from the handout. This approach helps refocus the client's attention on the topic being discussed, which is anger management. Choice A is not appropriate as it may disrupt the group session and does not address the client's behavior. Choice B, while important in understanding the client's background, does not address the immediate disruptive behavior. Choice C involves others to manage the client's behavior instead of direct intervention by the nurse, which may not be effective in this situation.

3. A client is admitted for bipolar disorder and alcohol withdrawal, depressive phase. Based on which assessment finding will the RN withhold the clonidine (Catapres) prescription?

Correct answer: A

Rationale: In this scenario, the correct answer is A. Clonidine, such as Catapres, is a medication that can lower blood pressure. Therefore, if a client has low blood pressure readings, like 90/62 mmHg to 92/58 mmHg, the registered nurse should withhold the clonidine prescription to prevent further lowering of blood pressure which could lead to adverse effects. Choices B, C, and D are incorrect because they are within normal ranges and do not present a contraindication for the administration of clonidine in this context.

4. 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.

5. A client with depression and a history of a recent suicide attempt is being discharged from the hospital. Which statement by the client indicates a need for further follow-up?

Correct answer: C

Rationale: The correct answer is C. When a client with depression and a history of a recent suicide attempt states, “I feel that I am completely recovered now,” it indicates a need for further follow-up. This statement suggests a potential lack of insight into the ongoing nature of depression and may lead to discontinuation of necessary treatment and support. Choices A, B, and D demonstrate positive and proactive attitudes towards managing depression and suicidal ideation, indicating a willingness to engage in treatment, therapy, and self-care practices.

Similar Questions

After surgery, a male client with antisocial personality disorder frequently requests a specific nurse be assigned to his care and becomes belligerent when another nurse is assigned. What action should the charge nurse implement?
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?
Which client statement suggests that the client is using a defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit?
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 client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care?

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