HESI RN
Quizlet HESI Mental Health
1. 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?
- A. I am here because the police thought I was doing something wrong
- B. At least I hit the wall instead of hitting the psychiatric aide
- C. I want to be here because I know it is the best psychiatric facility
- D. Don’t believe everything my family tells you, I am not crazy
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.
2. 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?
- A. Prevent the client from going into the kitchen until the hallucination subsides.
- B. Report the behavior to the client’s case worker to inform the family.
- C. Assign a UAP to stay with the client continually.
- D. Document the behavior in the client’s record and notify the HCP.
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.
3. A client with a recent diagnosis of bipolar disorder is attending a support group for the first time. Which statement made by the client indicates a need for further education about the disorder?
- A. “I will make sure to take my medications every day.”
- B. “I will avoid high-stress situations whenever possible.”
- C. “I know I can stop my medications when I am feeling better.”
- D. “I should monitor my mood changes closely.”
Correct answer: C
Rationale: The correct answer is C because it shows a misconception about bipolar disorder treatment. Stopping medications when feeling better can lead to a relapse or worsening of symptoms. Choice A is correct because medication adherence is crucial in managing bipolar disorder. Choice B is also a good strategy as stress management is important in symptom control. Choice D is a proactive approach to self-awareness and can help in recognizing early signs of mood changes.
4. A male client comes to the emergency center with an erection that will not resolve. The client reports that he is taking trazodone (Desyrel) for insomnia. Which information is most important for the nurse to ask this client?
- A. Have you taken any medication for erectile dysfunction?
- B. Are you experiencing any other sexual dysfunctions or problems?
- C. When was the last time you consumed alcohol?
- D. Do you have a history of angina or high blood pressure?
Correct answer: B
Rationale: In this scenario, the most important question for the nurse to ask the client is whether he is experiencing any other sexual dysfunctions or problems. This inquiry is crucial as it can help in determining if the persistent erection is a side effect of trazodone. Asking about medication for erectile dysfunction (Choice A) may not provide relevant information in this case, as the focus is on the potential side effects of trazodone. Inquiring about the last time the client consumed alcohol (Choice C) is not directly related to the situation at hand. Questioning about a history of angina or high blood pressure (Choice D) is important for overall assessment but is not as directly relevant to the immediate concern of the persistent erection potentially caused by trazodone.
5. A female client with obsessive-compulsive personality disorder is admitted to the hospital for a cardiac catheterization. The afternoon before the procedure, the client begins to keep detailed notes of the nursing care she is receiving and reports her findings to the RN at bedtime. What action should the nurse implement?
- A. Explain to the client that her behavior invades the rights of the nursing staff.
- B. Ask the client to explain why she is keeping a detailed record of her nursing care.
- C. Teach the client strategies to control her obsessive-compulsive behavior.
- D. Encourage the client to express her feelings regarding the upcoming procedure.
Correct answer: B
Rationale: Asking the client to explain why she is keeping a detailed record of her nursing care is the most appropriate action for the nurse to take in this situation. Understanding the client’s motivations for keeping detailed records can provide insight into her obsessive-compulsive behaviors and help manage them effectively. This approach allows for a non-confrontational exploration of the behavior. Choice A is incorrect because it may be perceived as confrontational and does not address the underlying reasons for the behavior. Choice C is incorrect because teaching strategies to control behavior should come after understanding the client's motives. Choice D is incorrect as it does not directly address the behavior of keeping detailed records, which is the immediate concern that needs to be addressed.
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