MENTAL HEALTH HESI 8
The nurse completes a physical assessment. When asked what brought her to the
hospital, the client replies that things just aren't right and begins to cry. After further
conversation, the client describes her mood as very sad now. She rarely goes out or
invites friends to visit. She admits that she feels like strangers are saying bad things
about her. Sometimes she hears a man's voice that is a little bit scary.
What is the priority focused nursing assessment? - Determine how long the client has
been hearing the voice and what it is saying.
Rationale: Determining if voices are being heard and the type of voices are priority. The
nurse must assess the content of the auditory hallucinations for the presence of
command hallucinations. Command hallucinations may be telling the client to harm
herself or others.
The client is assessed by the nurse, a social worker, and the healthcare provider (HCP).
Based on their assessments, hospitalization is recommended for psychotic depression.
Which behavior is inconsistent with depression? - Hearing a man's voice.
Rationale: Auditory hallucinations are inconsistent with depression and are more likely
to occur with psychoses. However, clients may experience a psychotic depression in
which there is evidence of psychosis.
The nurse asks the client to sign the consent for treatment.
If the client refuses treatment, which behaviors justify short-term involuntary treatment?
(Select all that apply. One, some, or all options may be correct.) - Unable to meet basic
self-care needs.
Rationale: Involuntary treatment can be initiated if the client is unable to meet basic self-
care needs in such a way that he or she is a danger to self.
States she has a plan to harm herself.
Rationale: Short-term involuntary care may be initiated to protect the client if she has a
plan to harm herself. It can also be initiated if she presents an intentional danger to
others.
The client signs the treatment form and is admitted to the mental health unit. During the
first days of hospitalization, she begins antidepressant therapy with fluoxetine 10 mg.
In what classification of drugs is the antidepressant fluoxetine? - Selective serotonin
reuptake inhibitor (SSRI).
Rationale: Fluoxetine is an SSRI antidepressant.
What is the major action of SSRI antidepressants? - Increase availability of serotonin.
Rationale: The major action of SSRIs is to selectively inhibit the reuptake of serotonin
and increase the availability of serotonin.
,The nurse understands that SSRIs are now more widely prescribed than tricyclics for
antidepressant therapy. What is the rationale? - Tricyclics have more dangerous side
effects.
Rationale: SSRIs are more widely prescribed than tricyclics because they have fewer
side effects, and tricyclics can be lethal in an overdose because they are cardiotoxic.
When the client receives fluoxetine, the nurse must explain the purpose and when to
expect therapeutic effectiveness. What should the nurse tell the client regarding when
she will begin to feel less depressed? - Generally within 1 to 4 weeks.
Rationale: In general, it takes 2 to 4 weeks for antidepressant effects to begin. However,
it depends on the individual, and some clients may feel effects start as soon as 1 week
or as late as 4 weeks. It is suggested that depression occurs when a depletion of
neurotransmitters in the synapse cause the transmitter receptors to increase. As the
antidepressants make more transmitters available, it takes the receptors several weeks
to return their numbers back to normal and allow normal synaptic activity.
The nurse should be aware of common side effects of SSRI antidepressants such as
fluoxetine. Which side effect should be communicated to the client that commonly occur
in clients who are taking SSRI antidepressants? - Gastrointestinal disturbances.
Rationale: GI disturbances such as nausea and diarrhea, as well as genitourinary side
effects such as sexual dysfunction, are common with SSRIs. SSRIs do not have
significant anticholinergic, cardiovascular, or sedative side effects.
The client also begins an atypical antipsychotic, risperidone, because she reports
hearing a "scary voice" upon admission. Although the client remains very withdrawn and
noncommunicative, the nurse must explain the purpose of risperidone. Which
explanation is best? - Risperidone will help the think more clearly.
Rationale: Antipsychotic medications target symptoms related to disorders of thinking
such as psychosis and behaviors associated with agitation and disorganization or
speech and behavior.
The nurse is reviewing the client's admission lab work on the third day of hospitalization.
Admission labs include thyroid profile, urinalysis, chemistry panel, pregnancy test, urine
drug screen, and VDRL (RPR) which tests for venereal disease.
A thyroid profile is important for several reasons. What role do thyroid levels play in
depression? - Hypothyroidism can lead to feeling sluggish and depressed.
Rationale: Thyroid levels can help detect hypothyroidism, which can lead to depression.
The nurse understands that a VDRL is routinely done on admission for which reason? -
It is a screening test for syphilis.
Rationale: A VDRL (RPR) is a serum screening test for syphilis, which can be
undetected and dormant and can cause cognitive impairment in later stages. If the
screening serum test is positive, a more specific test is required to make the diagnosis
of syphilis.
, When the client awakens in the morning, she sits for periods of time at the edge of her
bed. She does not initiate combing her hair, getting dressed, or going to breakfast.
Which intervention should the nurse implement? - Help the client with daily activities.
Rationale: When a client is very depressed, it is necessary to assist with daily activities
because the client has decreased energy. Physical care is more important with severe
depression.
Since the client has decreased energy, which additional intervention should the nurse
implement? - Plan a scheduled rest period.
Rationale: It is best to plan rest periods according to the client's energy level because
some clients feel best in the morning and others feel best in the evening.
As the nurse initially communicates with the client, which communication technique is
important? - Acknowledge the client's courage in seeking help, then offer to sit quietly
with the client.
Rationale: Offering nonjudgmental acceptance and companionship will help develop
trust. Acknowledging the step the client took in seeking help may restore the client's
sense of control over her situation.
According to the nursing progress notes, the client demonstrates decreased social
interaction, she rarely talks, she needs assistance to her room and appears confused.
The client only slept 30 minutes in the past 24 hours, and the daily graphics indicate
that she has slept an average of 2 hours in the past week. She is eating 50% of her
meals.
According to this data, what is the priority nursing problem? - Sleep disturbance.
Rationale: Considering Maslow's hierarchy, physiologic needs should be addressed
first, so this is the priority problem because the client is receiving inadequate sleep.
Eating 50% of her meals is acceptable, provided that the client is not losing weight.
Since the client is eating 50% of her meals, which nursing intervention should be
included on the treatment plan? - Weigh weekly and document.
Rationale: The most objective assessment related to the client's intake is frequent
weighing to document any changes in weight that should be monitored more closely.
One morning, the nurse takes the client's vital signs and notes her blood pressure is
141/108 mmHg. The progress notes indicate this is the third incidence of a high blood
pressure.
Which consideration by the nurse is accurate? - The client's diet, which consists of
primarily high sodium foods, could be contributing to her high blood pressure.
Rationale: A high sodium diet can lead to hypertension and fluid retention.
