MENTAL HESI 4 LATEST 2021 100% VERIFEID

MENTAL HESI 4 LATEST 2021 100% VERIFEID 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 1. intervention? A. 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 2. abuse? A. The nurse is assessing a client who is believed to have a borderline personality disorder. Which question is most important to include in this 3. assessment? A. 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 4. address? A. 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 5. provide? A. 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 6. first? A. A client is told that her infant will be stillborn. What is the most important action for the nurse to implement after the 7. birth? 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 8. nurse implement? A. Which nursing intervention should the nurse implement with parents who experience a fetal demise and express the wish not to see the 9. baby? A. 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 10. should the nurse respond? A. 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 11. respond? A. The nurse is planning the care for a client based on the psychoanalytical model. Which intervention should the nurse 12. include? A. 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 13. therapy? A. Which client should the nurse identify as the highest risk for the onset of stress-related 14. problems? A. 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 15. neurotransmitters? 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 16. respond? A. 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 17. to provide? 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 18. take? A. Which action is most important for the nurse to implement during the initial interview for a client who is admitted to the mental health 19. unit? 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 20. illness? A. A female client with severe depression is given information about the risks, benefits, alternatives, and expected outcomes of electroconvulsive therapy (ECT) and signs the informed consent for treatment. After the client's family leaves, the client tells the nurse, I signed the papers because my husband told me I will be deported if my depression is not cured. What information should the nurse report to the healthcare 21. provider? A male client tells the nurse that he plans to kill his spouse and her lover as soon as he is released from the hospital. What action should the nurse 22. implement? A. A male client is brought to the emergency department by a police officer, who reports the client was disturbing the peace by running naked in the street, striking out at others, and smashing car windows. Which behaviors should the client demonstrate to determine if he should be evaluated for involuntary commitment? (Choose all that 23. apply.) A. B. What action should the nurse take when a client who is psychotic proposes goals that are both unrealistic and 24. undesirable? A. A client is pacing in the hall near the nurses' station and swearing loudly. What response is best for the nurse to 25. provide? A. A client is responding to auditory hallucinations and shakes a fist at a nurse and says, Back off, witch! The nurse follows the client into the day room. What action should the nurse 26. implement? A. A male client with severe orthopedic injuries following a motor vehicle collision is irritable, angry, and belittles the nurses. While a nurse is changing the dressing over a laceration, the client screams, Don't touch me! You're so stupid that you'll make it worse! Which intervention is best for the nurse to 27. implement? A. A 35-year-old married woman works full-time in a factory and has been absent from work for three days at a time on several occasions. Each time she returns to work, she wears dark glasses to cover facial bruising. Her supervisor refers her to the occupational health nurse. What assessment question is most important for the nurse to 28. initially use? A. A female client presents to the emergency center with confusion, emotional numbness, and expresses to the nurse a feeling of disbelief that she was raped. The nurse determines the client is in the acute phase of rape-trauma syndrome. What action should the nurse implement 29. first? A. Which client outcome indicates improvement for a client who is admitted with auditory 30. hallucinations? A. The nurse is caring for an adult male client with catatonic schizophrenia who is mute and motionless. What is the priority nursing 31. diagnosis? A. A client with a history of alcoholism is admitted with a compound fracture of the femur after falling down the previous night. What additional assessment should be the priority focus for the 32. nurse? A. A client who is intoxicated is admitted for alcohol and multiple substance detoxification. The nurse determines that the client is becoming increasingly anxious, agitated, and diaphoretic. The client is also experiencing sensory perceptual disturbances and a clouded sensorium. What is the priority nursing intervention for this client at this 33. time? A. A female client comes to an outpatient therapy appointment intoxicated. The spouse tells the nurse, There wasn't anything I could do to stop her drinking this morning. What intervention should the nurse take 34. at this time? A. Which client statement should the nurse identify as most typical of a client with 35. mania? A. What nursing assessment is the priority focus for a client with major 36. depression? A. The nurse is caring for a client who received the first-time electroconvulsive therapy (ECT) a half hour ago. Which action should the nurse implement 37. first? A. A client with substance abuse is admitted to the mental health unit. Which action should be implemented by the nurse, and not delegated to a unlicensed assistive personnel 38. (UAP)? A. Which action should the nurse implement first for a client experiencing alcohol 39. withdrawal? A. The nurse is caring for a client who was admitted for alcohol detoxification 2 days ago. Which finding is most critical for the nurse to report to the healthcare 40. provider? A. During a one-to-one interaction, a male client describes the sadness he experienced when his mother died. Suddenly, the nurse begins to think about her grandmother's death. As a result, the nurse asked the client to describe his thoughts when he learned of his own mother's illness. What is the nurse 41. doing? A. 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 42. process? A. A female client with bipolar disorder, manic phase, is planning weekend activities with the other clients on the unit. The client interrupts the group, insists that they change their plans to a disco party, and begins to curse loudly when the group refuses to change the plans. Which intervention should the 43. nurse implement? A. Which action should the nurse implement during the termination phase of the nurse- client 44. relationship? A. Which statement made by an adolescent in group therapy should the nurse identify as a priority in planning 45. care? A. The nurse is caring for a female client who is admitted for depression with the nursing diagnosis, Self-esteem, chronic low. Which client response indicates to the nurse that the client has 46. improved self-esteem? During an inpatient therapy group session, a client tells the members that he hears voices that say his doctor is going to poison him. He continues, "I look around to see who's talking to me, and I can't see anybody." Another client replies, "I used to hear voices, too. I found out they were my imagination. The voices you hear aren't real either." Which phenomenon, common to groups, is exemplified in this 47. interchange? A. An adolescent who attempted suicide with a drug overdose arrives in the emergency department with an empty 30-tablet bottle of acetaminophen (Tylenol). Which action should the nurse 48. implement? A client on the mental health unit reports concerns about weight gain as a result of taking divalproex (Depakote) and requests assistance to fill out a menu. The nurse should initiate a referral to which healthcare team 49. member? A. During the admission of a male client to the mental health unit, the client tells the nurse that he had a panic attack today and ran out of the physician's office. Which question is most important for the nurse to ask this 50. client? A. The daughter of a female client with stage-1 Alzheimer's disease (AD) asks the nurse what changes should she expect her mother to demonstrate in this stage. What finding should the nurse tell the daughter is 51. common? A male client on a psychiatric unit becomes extremely agitated and begins to smash his head against doors. He seems frightened, and his verbalizations suggest he is experiencing distorted sensory perceptions. What action should the nurse take 15. first? During an admission assessment interview, a client states, "I do not use many drugs." How should the 16. nurse respond?