NU 473 HESI Psychiatric/Mental Health Practice Exam - Answered with Rationales
2 views 0 purchase
Course
NU 473
Institution
NU 473
NU 473 HESI Psychiatric/Mental Health Practice Exam - Answered with Rationales The nurse should include which interventions in the plan of care for a severely depressed client with neurovegetative symptoms? (Select all that apply.) o Permit rest periods as needed. o Speaking slowly and simply. o ...
NU 473 HESI Psychiatric/Mental Health Practice Exam The nurse should include which interventions in the plan of care for a severely depressed client with neurovegetative symptoms? (Select all that apply.) o Permit rest periods as needed. o Speaking slowly and simply. o Place the client on suicide precautions. o Observe and encourage food and fluid intake. o Encourage vigorous exercise and long walks on the unit. · Neurovegetative symptoms that accompany the mood disorder of depression incl ude physiological disruptions, such as anorexia, constipation, sleep disturbance, and psychomotor retardation. The client's plan of care should include measures that promote the client's comfort and well -being, such as rest, nutrition, suicide precautions, and simple communications. Vigorous exercise and long walks are not indicated for clients in a neurovegetative state. Which diet selection by a client who is depressed and taking the MAO inhibitor tranylcypromine sulfate (Parnate) indicates to the nurse that the client understands the dietary restrictions imposed by this medication regimen? o Hamburger, French fries, and chocolate milkshake. o Liver and onions, broccoli, and decaffeinated coffee. o Pepperoni and cheese pizza, tossed salad, and a soft dri nk. o Roast beef, baked potato with butter, and iced tea. · Foods with tyramine interact with MAOI antidepressant, such as Parnate, and can cause a hypertensive crisis that is life -threatening. Roast beef, potatoes, butter, and tea do not contain tyramine . The other selections contain tyramine and should be avoided by the client who is taking Parnate. An older male client in the intensive care unit who has been oriented suddenly becomes disoriented and fearful. Assessment of vital signs and other physical parameters reveal no significant change and the nurse formulates the client's problem as confusion related to ICU psychosis. Which intervention is most important for the nurse implement? o Move all machines away from the client's immediate area. o Attemp t to allay the client's fears by explaining the etiology of confusion. o Cluster care so brief periods of rest can be scheduled during the day. o Extend visitation times for family and friends. · The critical care environment confronts clients with an environment which is stressful and heightened by treatment modalities that may prove to be lifesaving. These stressors can result in isolation or sensory overload that leads to confusion. The best intervention is to cluster care to provide the client with uninterrupted rest periods. The other actions may not be possible. A male client is admitted to the psychiatric unit with a medical diagnosis of paranoid schizophrenia. During the admission procedure , the client looks up and states, "No, it's not MY fault. You can't blame me. I didn't kill him, you did." What action is best for the nurse to take? o Reassure the client by telling him that his fear of the admission procedure is to be expected. o Tell t he client that no one is accusing him of murder and remind him that the hospital is a safe place. o Assess the content of the hallucinations by asking the client what he is hearing. o Ignore the behavior and make no response at all to his delusional statem ents. · Further assessment is indicated and the nurse should obtain information about what the client believes the voices are telling him --they may be telling him to kill himself or the nurse. The other actions are not indicated. The nurse is assessing a client's intelligence. Which factor should the nurse remember during this part of the mental status exam? o Acute psychiatric illnesses impair intelligence. o Intelligence is influenced by social and cultural beliefs. o Poor concentration skills suggests limited intelligence. o The inability to think abstractly indicates limited intelligence. · Social and cultural beliefs have significant impact on intelligence. The other factors do not necessarily suggest limited intel ligence. A young adult male client, diagnosed with paranoid schizophrenia, believes that world is trying to poison him. What intervention should the nurse include in this client's plan of care? o Remind the client that his suspicions are not true. o Ask one nurse to spend time with the client daily. o Encourage the client to participate in group activities. o Assign the client to a room closest to the activity room. · A client with paranoid schizophrenia has difficulty with trust and developing a trusting relationships, the plan of care should include providing one nurse to spend time with the client daily, which is likely to be therapeutic for this client. The other actions are too stressful for the client and not indicated. The nurse is assessin g a client who is admitted with a diagnosis of depression. Which findings is characteristic of depression? o Grandiose ideation. o Self -destructive thoughts. o Suspiciousness of others. o A negative view of self and the future. · Negative self -image and feelings of hopelessness about the future are specific findings in depression. The other findings are not the underlying manifestations in depression. The nurse is taking a history for a female client who is requesting a routine female exam. Which assessm ent finding requires follow -up? o Menstruation onset at age 9. o Contraceptive method includes condoms only. o Menstrual cycle occurs every 35 days. o "Black -out" after one drink last night on a date. · A "black -out" typically occurs after ingestion of a lcohol beverages that the client has no recall of experiences or one's behavior and is indicative of high blood alcohol levels. The client's experience of a "black -out" after one drink is suspicious of the client receiving a "date rape" drug, such as fluni trazepam ("Rohypnol"), and needs additional follow -up. The other findings do not need follow -up at this time. The nurse is preparing to administer phenelzine sulfate (Nardil) to a client on the psychiatric unit. Which side effect reported by the client is related to administration of this drug? o My mouth feels like cotton. o That stuff gives me indigestion. o This pill gives me diarrhea. o My urine looks pink. · A dry mouth is an anticholinergic response that is an expected side effect of MAO inhibitors, such as phenelzine sulfate (Nardil). The other subjective reports are not related to this medication. An adult female client is admitted to the psychiatric hospi tal with a diagnosis of bipolar disorder, manic phase. She is demanding and active. Which intervention should the nurse include in this client's plan of care? o Schedule her to attend various group activities. o Reinforce her ability to make her own decis ions. o Encourage her to identify feelings of anger. o Provide a structured environment with little stimuli.
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller NurseHenny. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $17.99. You're not tied to anything after your purchase.
