MENTAL HESI 3 Questions/Answers

MENTAL HESI 3 MENTAL HESI 3 1. Which technique is the most important therapeutic tool a nurse should use to provide quality care to a psychiatric client? A. Context. B. Self-analysis. Correct C. Counter transference. D. Therapeutic self-disclosure. 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 (B) is a primary tool used by the nurse to establish therapeutic empathy and achieve authentic, open, and personal communication with a client. Although (A, C, and D) may occur in a nurse-client relationship, they may not contribute to establishing a therapeutic relationship. 2. The nurse completes an emergency admission of a male client with schizophrenia who has not been taking his antipsychotic medications. The client is pacing, is extremely irritable, and has a blood pressure of 146/96. What is the priority nursing action? A. Encourage the client to stop pacing and sit down. B. Reevaluate the client's blood pressure in an hour. Correct C. Direct the client to attend recreational therapy. D. Review the client's baseline blood pressure. The client is irritable and pacing, which can contribute to the elevated BP, so reevaluation of the client's BP in an hour (B) allows time for the excitement and stress of the admission process to abate. (A) is likely to increase the client's agitated state. Recreational therapy (C) provides another environmental stimulus, which can contribute to the client's anxiety. (D) is helpful, but the most immediate action is to retake the blood pressure in one hour. 3. A young adult female client with panic disorder arrives in the Emergency Center with a 4- day history of chest pain that began when her boyfriend left her. Initial assessment reveals normal cardiopulmonary findings. Which information is most important for the nurse to obtain? A. Drugs taken in last 7 days. Correct B. Family history of suicide. C. Usual coping mechanisms. D. Frequency of anxiety attacks. Use of prescribed, over-the-counter, and illicit drugs (A) is the most important information to obtain when planning care because drugs are likely to influence the client's behavior and ability to cope with stressful situations. (B, C, and D) are worthwhile assessment findings, but they do not have the priority of (A). 4. The nurse is planning care for a client with major depression who is admitted to the unit after a recent suicide attempt. Which intervention has the highest priority for inclusion in this client's plan of care? A. Search the client's personal belongings. Correct B. Introduce the client to others on the unit. C. Ask the client about recent stressful events. D. Move to a room that allows close observation. To ensure that the client has not acquired some means to inflict self harm, a routine search of personal belongings (A), which is a common safety measure and policy, should be implemented until the client stabilizes and suicidal ideations abate. (B) is a component of the therapeutic milieu, but the client's readiness to interact with others should be assessed first. Although recent stressors (C) may have precipitated the suicide attempt, it is more important to ensure the client's safety from self-harm. Close observation should be initiated (D), but it is most important that any hazardous items are removed from the client's possession. 5. A 6-year-old girl with severe birth defects and mental retardation 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? A. Prepare the child for cast placement. B. Evaluate the intellectual functioning of the child. C. Evaluate the child for other injuries. Correct D. Ask the child to explain the accident. The nurse should evaluate the child for other injuries because a 6-year-old child with a low-level fall that results in a fracture should be considered a possible victim of child abuse, until proven otherwise (C). (A) has a lower priority than (C). (B) is not within the scope of nursing practice and should be referred to someone who is an expert. (D) is unrealistic. 6. An older client is admitted to a psychiatric hospital with the diagnosis, "Major depression, single episode." Which laboratory value is most important for the nurse to report to the healthcare provider immediately? A. Increased serum creatinine level. B. Positive rapid plasma reagin (RPR). C. Increased thyroid stimulating hormone (TSH). Correct D. Elevated serum calcium level. The healthcare provider should be notified of (C) immediately. An increased TSH suggests a low thyroxine level because the TSH is trying to stimulate thyroxine production, and hypothyroidism symptoms mimic those of depression. (A) often increases with aging. (B) is indicative of syphilis and should be reported, but does not have the priority of (C). (D) has implications for other illnesses, such as non-Hodgkin's lymphoma or hyperparathyroidism. 7. The daughter of a 79-year-old male client tells the nurse that her father is becoming increasingly forgetful. Which finding indicates that the client needs further evaluation of cognitive function? A. Repeats the same stories to different family members or friends. B. Cannot mentally retrace objects that were recently misplaced. Correct C. Cannot remember instructions to program an electronic device. D. Forgets a planned event, then remembers the event a short while later. Inability to retrace misplaced objects (B) is an indicator of possible cognitive impairment that requires further assessment. (A, C, and D) are examples of benign forgetfulness. 8. A 13-year-old female client is admitted to the Emergency Department because she reports being raped. When the male unlicensed assistive personnel (UAP) enters the room to obtain her vital signs, she begins screaming for her mother and curls up in the corner of the room. What action should the nurse implement? A. Reassure client that the male UAP is a staff member who wants to help her. B. Tell the client that her fear is understandable under these circumstances. C. Reassign an all-female healthcare team to the client until her fear subsides. Correct D. Ask her mother to please stay with her throughout the assessment procedures. A traumatized client needs to be in a non-threatening environment, and reassigning this client to all-female personnel is likely to reduce her anxiety (C). (A) is negating her fear. While validating the client's feeling (B) is important, this statement does not specifically address the client's issue with the male UAP. (D) might be helpful, but it ignores the anxiety the client feels about the presence of a male UAP. 9. At the end of a group therapy session, a client who is hospitalized for psychosis falls to the floor when attempting to stand. What intervention should the nurse implement first? A. Ask a group member to seek help. Correct B. Obtain the client's blood pressure. C. Position in a recovery position. D. Assess the client's level of orientation. First, help should be obtained while the nurse remains with the client (A). Next, assessment of the client (B and D) should be completed. Lastly, the client should be positioned (C) to prevent aspiration while recovering. 10. The nurse is planning care for a female client with depression who cries when asked to make her menu selections. Which therapy group is likely to be most beneficial for this client? A. Coping skills. Correct B. Physical exercise. C. Grief management. D. Social support. Ineffective coping skills (A) are characteristic of depression, and based on this client's symptoms, group therapy that focuses on coping skills is likely to be most beneficial. (B, C, and D) are important groups, but they are less likely to be as beneficial as (A). 11. The nurse is planning care for a client with major depression who is admitted to the unit after a recent suicide attempt. Which intervention has the highest priority for inclusion in this client's plan of care? A. Search the client's personal belongings. Correct B. Introduce the client to others on the unit. C. Ask the client about recent stressful events. D. Move to a room that allows close observation. To ensure that the client has not acquired some means to inflict self harm, a routine search of personal belongings (A), which is a common safety measure and policy, should be implemented until the client stabilizes and suicidal ideations abate. (B) is a component of the therapeutic milieu, but the client's readiness to interact with others should be assessed first. Although recent stressors (C) may have precipitated the suicide attempt, it is more important to ensure the client's safety from self-harm. Close observation should be initiated (D), but it is most important that any hazardous items are removed from the client's possession.