MENTAL HESI 4

MENTAL HESI 4 1. A woman admitted to the Emergency Department is bleeding profusely from a patch where hair was lost from her scalp. She is accompanied 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? A. Notify the local police of a suspected spousal abuse situation. B. Ask the hospital security to remove the husband from the treatment room. C. Reassure the husband that his wife will be treated well while he is in the waiting area. D. Require the husband to leave the cubicle while the client is being treated. Correct 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, and (D) is the best method of providing this separation. (A) is not the priority at this time, and permission to notify the police should be obtained from the client. (B) is premature. Abusive husbands are unlikely to respond to manipulation (C) and are also unlikely to leave based on reassurances alone. 2. 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? A. Verbalizes an acceptance of health status. B. Expresses his feelings of satisfaction with care. Correct C. States that the frequency of abuse has decreased. D. Describes the potential danger of his situation. Abuse cessation should result in the client feeling satisfied with his care (B). (A) is not identified as an issue. Total abuse cessation is the goal, not (C). (D) is of lesser importance than satisfaction with care. 3. 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? A. At what age did you begin to exhibit symptoms? B. Do you have a family history of borderline disorder? C. How often do you drink alcoholic beverages? D. Do you frequently have temper tantrums? Correct Those with a borderline personality disorder demonstrate intense outbursts of anger, so (D) is the most important question to ask. (A, B, and C) provide worthwhile information, but do not have the priority of (D) when assessing a client who is suspected of having a borderline personality disorder. 4. 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? A. Sexually transmitted diseases. B. Annual gynecologic examination. C. Monthly breast self-examination. D. Domestic violence interventions. Correct 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 (D). Although (A) can be transferred by skin contact or bodily fluids, they are not immediately life threatening. All women, including those involved in same sex relationships, should receive a screening gynecologic examination (B). Homosexual women have the same risk for breast cancer (C) as heterosexual women. 5. 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? A. Yes, the treatment program you attended has an excellent success profile. B. Can you tell me more about what you mean when you say that your problems with alcohol are now behind you? Correct C. You are likely to have a difficult time staying sober if you think that your problems with alcohol are behind you. D. Do you know what 'one day at a time' means for those who have problems with alcohol? 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 the feelings (B). (A) avoids dealing with the client's misperception. (C) is threatening, and (D) could be interpreted as condescending. 6. 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? A. Encourage him to share his feelings more appropriately. B. Express concern over his disappointment. Correct C. Arrange to have a clergy person visit. D. Administer a PRN prescription for an antianxiety drug. Addressing the client's disappointment (B) enables the client to express feelings of frustration in a safe environment. (A) is dismissive, non-supportive, and could incite defensiveness. (C) may be indicated after other interventions are implemented. (D) should be a last resort because clients with liver failure have difficulty metabolizing medications. 7. A client is told that her infant will be stillborn. What is the most important action for the nurse to implement after the birth? A. Ask the family if they would like to see and hold the infant after birth. Correct B. Inquire if the parents want a picture taken after the infant is born. C. Discuss with the parents which funeral home should be notified. D. Find out if the client has a special outfit for the infant after the birth. Interventions and support from the nursing staff during a prenatal loss are extremely important in the grief process and healing of the parents. 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 (A). (B, C, and D) should be done after determining the parents' wishes and providing the opportunity for bonding and closure with their infant. 8. 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? A. Ready the client for discharge. B. Notify pastoral care to offer the client a blessing. C. Ask the client what name she had picked out for the infant. Correct D. Inquire if the client would like to see what was obtained from her D&C. 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 (C) provides an opportunity to offer support. (A) should be implemented upon direction of the healthcare provider. Although it may be therapeutic to offer religious support (B), the client should first be allowed to ventilate her feelings. (D) may be traumatic for the client. 9. Which nursing intervention should the nurse implement with parents who experience a fetal demise and express the wish not to see the baby? A. Tell them there is nothing to fear. B. Insist that they hold infant so they can grieve. C. Respect their wishes and release the body to the morgue. D. Keep the body available for a few hours in case they change their minds. Correct 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 (D) in the event they change their mind after the initial shock. (A) is non-supportive. (B) imposes the nurse's opinion and does not allow for individual expressions of grief. (C) does not provide a ready opportunity for the parents to hold the infant if they change their minds later. 10. 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? A. The goal of the individual is one of growth, health, autonomy, and self-actualization. B. All people have the right to an equal opportunity for adequate health care. C. Dependence on an extensive support system is needed to overcome any addiction. D. The client must participate in making decisions about his/her own physical and mental health. Correct 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 (D). (A, B, and C) are components in addiction recovery, but do not indicate the client's responsibility and primary commitment for decision-making about his/her health. 11. A client who is admitted with the chief complaint of feeling depressed tells the nurse, I want to feel normal again. How should the nurse respond? A. How long have you felt this way? B. We are all here to help you get better. C. What do you think the hospital can do for you? D. Tell me more about how things are with you. Correct When a client offers psycho-emotional complaints as the reason for admission, open-ended statements that seek clarification and elaboration provide the nurse with information about the client's life experiences that helps the nurse empathize, establish rapport, and support the client while reexamining and expressing feelings. (A and C) are short answer responses that do not allow the client to vent. (B) dismisses the client's statement and is not therapeutic. 12. The nurse is planning the care for a client based on the psychoanalytical model. Which intervention should the nurse include? A. Emphasize the client's strengths and assets. B. Teach the importance of medication compliance. C. Offer the client psychoeducational materials to read. D. Focus on the client's positive or negative feelings toward the nurse. Correct Interactions and interventions that focus on the client's positive or negative feelings toward the nurse (D) are based on the psychoanalytical model of mental health care. (A, B, and C) are not interventions associated with the psychoanalytical model. 13. A female client responds to the nurse with negative comments and antagonistic behavior. The nurse tells the client that she is unconsciously casting the nurse in the role of the client's mother. The nurse's feedback is based on which model of therapy? A. Medical. B. Existential. C. Interpersonal. D. Psychoanalytical. Correct The psychoanalytical model (D) uses concepts that interpret and focus on working through previously unresolved conflicts. The medical model (A) focuses on the diagnosis of a mental illness and its subsequent treatments, such as somatic treatments, pharmacotherapy, and electroconvulsive therapy. The existential model (B) focuses on the person's experience in the here and now, with much less attention focused on the person's past. The interpersonal model (C) focuses on the belief that behavior evolves around interpersonal relationships. 14. Which client should the nurse identify as the highest risk for the onset of stress-related problems? A. A man whose new business is growing slowly, who plans to adopt a child with his wife, and says, I think I'm in control of my destiny. B. A woman who is graduating from college, getting married in one month, and states, I'm anticipating the changes these events will make in my life. C. A client who is passed over for promotion, quits a job to start a new business, and states, This is just one of a series of challenges I've faced in my life. D. A person whose father died three months ago, who is losing a job due to company downsizing, and states, Living with loss and the threat of loss makes me feel helpless. Correct A client who is dealing with two stressful life events and expresses a cognitive appraisal of loss and helplessness (D) is at the highest risk for a stress-related health problem. (A, B, and C) describe persons who are coping with change using healthy strategies, such as perceiving change as challenging, expressing commitment to change, and believing they have control over their life paths. 15. The client with depression asks the nurse, What are neurotransmitters? My doctor thinks my problem may lie with the neurotransmitters in my brain. What information should the nurse use to support an explanation of neurotransmitters? A. Chemical messengers that cause brain cells to turn on or off. Correct B. Areas of the brain that are responsible for controlling emotions. C. Clumps of cells that alert the other brain cells to receive messages. D. Web-like structures that provide connections among parts of the brain. Neurotransmitters are chemicals manufactured in the brain that are responsible for exciting or inhibiting brain cells to produce an action (A). Neurons are clumps of cells (C) that alert the other brain cells to receive messages. The limbic system is the area of the brain responsible of controlling emotions (B). Astrocytes are glial cells that are web-like structures that connect blood vessels to neurons in the brain (D). 16. A client is scheduled to complete a positron emission tomography (PET) scan. The client asks the nurse to explain the reason the test was prescribed. How should the nurse respond? A. Images indicate the presence of tumors and scars. B. The scan clearly outlined structures of the brain. C. Results show activity in various portions of the brain. Correct D. PET shows biochemical levels of neurotransmitters. The results of a PET scan (used to detect cerebral activity in depression, schizophrenia, and Alzheimer's disease) shows brightly colored cerebral areas where an accumulation of a radioactively tagged glucose is used as a tracer to visualize brain activity (C), blood flow, and glucose metabolism. (A, B, or D) are not revealed by a PET scan. 17. A client with panic disorder tells the nurse, This illness is awful. I'm frightened that I will always be this way and that there's no hope for me. What is the best information for the nurse to provide? A. Panic disorder is treatable in a number of different ways, including medication. Correct B. Understanding the fact that a cure is not attainable helps the client learn to adjust. C. This disorder is a biologically determined hereditary disease that has no cure. D. Evidence based practice indicates that neuroleptic drugs can be used prophylactically. To foster the client's ability to cope, effective treatment options for panic disorder, such as desensitization, cognitive restructuring, relaxation, and psychotropic medications (A), should be discussed. (B, C, and D) do not provide accurate information. 18. A female client who is admitted for treatment of uncontrolled diabetes mellitus is withdrawn and tearful. She complains she has gained excessive weight because she hates her diet, hates taking insulin, and just wants to be normal again. What therapeutic action should the nurse take? A. Assist the client in verbalizing distress about the disease. B. Inquire about emotional factors affecting the client's present condition. Correct C. Assess priorities to be set for the client's overall nursing care plan. D. Encourage the client to emotionally accept the chronicity of the disease. Holistic care considers biological, psychological, and sociocultural factors that influence one's health status. The client is giving clues to psychological distress, so assessment for emotional factors that have impacted the client's present condition (B) should be made. The client is expressing distress, so (A) is redundant. Although priorities (C) should be determined, the client's current emotional distress should be addressed at this time. (D) is not indicated at this time. 19. Which action is most important for the nurse to implement during the initial interview for a client who is admitted to the mental health unit? A. Establish rapport in each phase of the nurse-client relationship. Correct B. Determine the client's ability to communicate effectively. C. Reflect on previous psychiatric interviews the nurse has performed. D. Ensure data is collected and recorded in a systematic sequence. A client with whom the nurse establishes rapport (A) during the initial interview and in each phase of the nurse-client relationship feels understood by the nurse and is more likely to cooperate and provide feedback during the admission process. Although the ability to communicate (B) is a component of the client's recovery, it is not always needed to establish rapport or maintain a therapeutic relationship. Experience (C) strengthens the therapeutic self, but it not the most important skill used during the initial interview. Systematic collection and documentation of data (D) ensures a comprehensive and complete assessment, which is dependent upon the use of rapport and the therapeutic self. 20. When assessing a client's emotional intelligence, which client capabilities should the nurse focus the interview on with a client diagnosed with a chronic mental illness? A. Linguistic and musical abilities. B. Interpersonal and intrapersonal skills. Correct C. Bodily kinesthetic and spatial abilities. D. Logical mathematics and linguistic abilities. Interpersonal and intrapersonal intelligence form one's personal intelligence or emotional quotient, so the nurse should focus inquiries on social skills (B). (A and D) assesses cognitive and mental status. (C) determines neurophysical interpretation of one's body within the environment, but does not assess emotional intelligence. ...............................................................