A client on the mental health unit is becoming more agitated, shouting at the staff, and pacing in the hallway. When the PRN medication is offered, the client refuses the medication and defiantly sits on the floor in the middle of the unit hallway. What nursing intervention should the RN implement ...
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Hesi Psych Mental Health Exit Exam (V1, V2, V3) (TB) study guide with complete solution rated A+ 1 A client on the mental heal th unit is becoming more agitated, shouting at the staff, and pacing in the hallway. When the PRN medication is offered, the client refuses the medication and defiantly sits on the floor in the middle of the unit hallway. What nursing intervention should the RN implement first? - answer ;Take other clients in the area to the client lounge A client is admitted to the mental health unit and reports taking extra anxiety medications because, "I'm so stressed out. I just want to go to sleep." The RN should plan one on one observation of the client based on which statement? - answer ;"I don't want to walk. Nothing matters anymore." A male hospital employee is pushed out the way by a female employee because of an oncoming gut hey. The pushed employee becomes very angry and swings at the female employee. Both employees are referred for counseling with the staff psychiatric RN. Which factor in the pushed employee's history is most related to the reaction that occurred? - answer ;Was physically abused by his mother. The RN documents the mental status of a female client who has been hospitalized for several days by court order. The client states, "I don't need to be here" and tells the RN that she believes the television talks to her. The RN should document these asse ssment findings in which section of the mental status exam/ - answer ;Insight and judgement A client is admitted to the mental health unit reports shortness of breath and dizziness. The client tells the RN. "I feel like I'm going to die." Which nursing pr oblem should the RN include in this client's plan of care? - answer ;Moderate anxiety A female client who is wearing dirty clothes and has foul body odor, comes to the clinic reporting feeling scared because she is being stalked. What action is most impor tant for the RN to take? - answer ;Offer the client a safe place to relax before interviewing her The RN leading a group session of adolescent clients gives the members a handout about anger management. One of the male clients is fidgety, interrupts peers when they try and talk, and talks about his pets at home. What nursing action is best for the RN to take? - answer ;Redirect him by encouraging him to read from the handout A male adolescent was admitted to the unit two days ago for depression. When the mental health RN tries to interview the client to establish rapport, he becomes very irritated and sarcastic. Which action os best for the RN to take? - answer ;Offer to play a game of cards with the client A male adult is admitted because of an acetamino phen (Tylenol) overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client's discharge plan? - answer ;Do not take any over the counter meds After r eceiving treatment for anorexia, a student asks the school RN for permission to work in the school cafeteria as part of the school's work study program. What action should the RN take? - answer ;Recommend assignment to the receptionist's office The RN acc epts a transfer to the mental health unit and understands that the client is distractible and is exhibiting a decreased ability to concentrate. The RN only has 15 minutes to talk to the client. To develop treatment plan for this client, which assessment os most important for the RN to obtain? - answer ;Mental status examination Hesi Psych Mental Health Exit Exam (V1, V2, V3) (TB) study guide with complete solution rated A+ 2 A male client who recently lost a loved one arrives at the mental health center and tells the RN he is no longer interested in his usual activities and has not slept for several day s. Which priority nursing problem should the RN include in the client's plan of care? - answer ;Sleep deprivation A male client with long history of alcohol dependency arrives in the emergency department describing the feelings of bugs crawling on his bod y. His blood pressure is 170/102, his pulse rate is 110 bpm, and his blood alcohol level os 0mg/dL. Which prescription shold the RN administer? - answer ;Lorazepam (Ativan) A client who refuses antipsychotic medications disrupts group activities, talks wi th nonsensical words and wanders into client's rooms. The RN decides that the client needs constant observation based on which of these assessment findings? - answer ;Wanders into the clients rooms A client with schizophrenia explains that she has 20 chil dren and then very seriously points to the RN and explains that she os one of them. What is the most therapeutic response for the RN to provide/ - answer ;"My name tag shows that I am an RN here." A high school girl reveals to the high school RN that she has been engaging in self - induced vomiting as weight -control measure. Which initial assessment should the RN focus on with this adolescent? - answer ;Frequent bingeing and purging behaviors. Narcan was administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate(Vicodin). Within 15 minutes, the client is alert and oriented. In planning nursing care, which intervention has the highest priority at this time? - answer ;Observe the client for further narcotic efffect s Following surgery, a male client with antisocial personality disorder frequently requests that a specific RN be assigned to his care and is belligerent when another RN is assigned. What action should the charge RN implement? - answer ;Advise the client that assignments are not based on the client's request When preparing to administer a prescribed medication to a homeless male at a community clinic, the client tells the RN that he usually takes a different dosage. What action should the RN take? - answer ;Withhold the medication until the dosage can be confirmed A client with depression remains in bed most of the day and declines activities. Which nursing problem has the greatest priority for this client> \? - answer ;Refusal to address nutritional needs HESI Mental Health RN V1 -V3 2022 - answer ; A nurse is explaining a fire drill rout ine to a group of clients. A client becomes disruptive and continually interrupts the group. What is the nurse's best response? - answer When you interrupt, I cannot explain what to do to the group. A client comes in after being in a car accident and is e xperiencing alcohol withdrawal, magnesium level of 1.1, cardiac dysrhythmias. What would you give first? - answer Magnesium When performing a Mental Status Exam (MSE) on a client which assessment intervention would best assist the nurse? - answer Ask the client to interpret the proverb a stitch in time saves nine. Hesi Psych Mental Health Exit Exam (V1, V2, V3) (TB) study guide with complete solution rated A+ 3 A women was just told of her husbands diagnosis of terminal cancer. What would the nurse offer for the wife? - answer How would you like to be involved with your husbands care? A nurse is to re move staples form an abdominal incision, the client is very anxious. What is the most important intervention? - answer Attempt to distract the client with general conversation A man diagnosed with bipolar disorder states, "I don't understand. I believe in God and have not done anything to deserve this." What is the nurses best response? - answer You did not do anything wrong. You have a chemical imbalance in your brain. A client becomes upset when the nurse he requests is not assigned to him. what is the nurses best response? - answer Advise the client that nursing assignments are not based on client requests. A client needs to wash her hands for 2 hours before able to go on with her morning. She doesnt want to sit on the chairs in the dayroom for fear of getting dirty. What is this mechanism? - answer Compulsion A client in group is talking about her prostitution. The nurse asks her if she was abused by her parents. She states, my mother ran my father out when I was young. What defense mechanism was used ? - answer Repression A woman calls the crisis hotline and says she has a loaded gun and is going to kill herself. To maintain patient confidentiality, what would the nurse do? - answer Contact the person the client chooses to go to the home and remove t he weapon A client with anger management issues uses belt making and bangs the leather heavily. What defense mechanism is being used? - answer sublimation A bipolar client comes to the clinic and tells the nurse that the next time she sees her sister she is going to kill her. What should the nurse do? - answer Inform the sister What would then nurses highest priority for a newly admitted depressed client upon admission? - answer The nurse should go through the clients belongings Who is most prone to being abused? - answer Females over 75 living with families A client in the dayroom had tipped over a table and is escalating and has picked up a chair which she is threatening to throw at another client. What should the nurse do firs t? - answer Go and get more staff assistance A woman who is psychotic is carrying all of her belongings around with her because she is afraid that someone will steal it. What is the best way to establish trust? - answer Make brief contact with the client throughout the day In adolescent group, you are discussing a handout on anger management. A client is becoming increasingly interruptive and talking about his home and pets. What is the nurses most appropriate response? - answer Redirect the client to re ad the handout What is the most important intervention for a client with bulimia? - answer Plan scheduled meals A client comes in the ED with DTs. What should the nurse do first? - answer Administer Ativan A client who is refusing to take his medication is wandering on the unit and going in and out of residents rooms. What is the priority? - answer Wandering in and out of other clients rooms A nurse observes a client in the dayroom talking to himself. What should the nurse do first? - answer Ask the cli ent if he is currently hearing voices
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