MENTAL HESI V1 2021 1-A 6-year-old girl with severe birth defects who is mentally disabled is brought to the emergency room because of a broken arm. The caregiver reports that the girl sustained the injury when she fell from her wheelchair. Which intervention is most important for the nurse to impl...
, MENTAL HESI V1 2021
1-A 6-year-old girl with severe birth defects who is mentally disabled is brought to
the emergency room because of a broken arm. The caregiver reports that the girl
sustained the injury when she fell from her wheelchair. Which intervention is
most important for the nurse to implement?
Evaluate the child for other injuries.
Rationale: Because a 6-year-old child with low level fall that results in a fracture should
be considered a possible victim of child abuse, until proven otherwise.
2-The community health nurse facilitates a substance abuse prevention group for
a homeless population. Which statement demonstrates that a client has a realistic
understanding of the recovery process?
"By learning what led to my latest relapse, I know what to do in the future."
Rationale: Recovery is a lifelong process in which clients must constantly learn and
apply new behaviors to replace ineffective ones. Every attempt toward recovery
improves long-term chances of success, so those who learn from their relapses
demonstrate an understanding of the process.
3-A woman admitted to the Emergency Department is bleeding profusely from a
patch where her hair was lost from her scalp. She is accompanying by her
husband who tells the nurse that his wife caught her hair on the railing and pulled
it out when she fell down the stairs. The husband is solicitous of his wife and
quickly answers questions on her behalf. He attempts to comfort his wife by
saying to her, "I am right here with you, dear. Nothing can keep us apart." What is
the priority nursing intervention?
Require the husband to leave the cubicle while the client is being treated.
Rationale: This client should be questioned about the possibility of spousal abuse and
cannot answer truthfully in the presence of the perpetrator, so separating the couple is a
priority.
4- While assessing a 70-year old male client, a nurse working in the outpatient
clinic notices bruises on the client's chest. The client admits that his daughter,
who is his caregiver, becomes frustrated and sometimes hits him. What is the
priority outcome for the elderly client who sustained the abuse?
Expresses his feelings of satisfaction with care.
Rationale: Abuse cessation should result in the client feeling satisfied with his care.
,5- The nurse is assessing a client who is believed to have a borderline personality
disorder. Which question is most important to include in this assessment?
"Do you frequently have temper tantrums?"
Rationale: Those with a borderline personality disorder demonstrate intense outbursts
of anger.
6-A nurse is teaching a female client who is in a homosexual relationship about
women's health. Which topic is the most important for the nurse to address?
Domestic violence interventions.
Rationale: Since all women, regardless of sexual orientation, are at risk for domestic
violence that can be potentially lethal, this is the most important topic for the nurse to
address.
7-A client who abuses alcohol says to the nurse, "I am glad I went in for
treatment. Now my problems with alcohol are all behind me." Which response is
best for the nurse to provide?
"Can you tell me more about what you mean when you say that your problems with
alcohol are now behind you?"
Rationale: Those who attend alcohol treatment programs and Alcoholics Anonymous
never put drinking problems behind them and describe alcoholics as only one step away
from a slip with maintaining sobriety. The nurse should use reflection and encourage the
client to further describe his feelings.
8-A male client who is on the liver transplant list is called to the unit for a possible
transplant. When learning that the donor organ is no longer available, the client
slams doors and shouts vulgarities about his situation. What action should the
nurse implement first?
Express concern over his disappointment.
Rationale: Addressing the client's disappointment enables the client to express feelings
of frustration in a safe environment.
9-A client is told that her infant will be stillborn. What is the most important action
for the nurse to implement after the birth?
Ask the family if they would like to see and hold the infant after birth.
, Rationale: Interventions and support from the nursing staff during a prenatal loss are
extremely important in the grief process and healing of the patients. Research had
shown it is most helpful for a mother and father to see and hold their deceased infant
after delivery, so the parents should be given this opportunity initially after birth.
10-A client who has a miscarriage at 10-weeks gestation tells the nurse that she
already purchased some baby things and picked out a name. After the surgical
dilation and curettage (D&C), the client wants to go home as soon as possible.
Based on the client's statements, which action should the nurse implement?
Ask the client what name she had picked out for the infant.
Rationale: The client's cues about her preparation for the baby indicate her need to
express her feelings of loss, so encouraging further discussion about the infant's name
provides an opportunity to offer support.
11-Which nursing intervention should the nurse implement with parents who
experience a fetal demise and express the wish not to see the baby?
Keep the body available for a few hours in case they change their minds.
Rationale: Grieving parents should be encouraged to hold their infant after death to
facilitate closure. If parents are hesitant about seeing or holding their dead infant, the
fetus should be available for a few hours. in the even they change their mind after the
initial shock.
12-A client actively involved in substance addiction therapy frequently relapses
into benzodiazepines and alcohol use. The client tells the nurse, "I don't think I
will ever be able to kick this habit." How should the nurse respond?
The client must participate in making decisions about his/her own physical and mental
health.
Rationale: The client has the right to self-determination and the responsibility to make a
decision to pursue health or illness, so the client must actively participate.
13-Which technique is the most important therapeutic tool a nurse should use to
provide quality care to a psychiatric client?
Self-analysis.
Rationale: Self-analysis is a tool for the nurse to examine oneself, view one's
responses in various mental and emotional moments, and provide a sense of how
sensitive care should be provided relative to one's own needs, so self-analysis is a
primary tool used by the nurse to establish therapeutic empathy and achieve authentic,
open, and personal communication with a client.
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