MENTAL HESI 5 LATEST 2021 100% VERIFEID

MENTAL HESI 5 LATEST 2021 100% VERIFEID A male client is admitted to the mental health unit because he was feeling depressed about the loss of his wife and job. The client has a history of alcohol dependency and admits that he was drinking alcohol 12 hours ago. His temperature is 100.0 F, pulse is 100, and blood pressure is 142/100. The nurse plans to give the client lorazepam (Ativan) based on which priority 1. nursing diagnosis? a. A nurse working in the emergency room of a children's hospital admits a child whose injuries could have resulted from abuse. Which statement most accurately describes the nurse's responsibility in cases of suspected child 2. abuse? a. A child is brought to the emergency room with a broken arm. Because of other injuries, the nurse suspects the child may be a victim of abuse. When the nurse tries 3. to a. A client, who is on a 30-day commitment to a drug rehabilitation unit, asks the nurse if he can go for a walk on the grounds of the treatment center. When he is told that his privileges do not include walking on the grounds, the client becomes verbally abusive. Which approach should the 4. nurse take? a. A client who is known to abuse drugs is admitted to the psychiatric unit. Which medication should the nurse anticipate administering to a client who is exhibiting benzodiazepine withdrawal 5. symptoms? a. A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing 6. care? a. A 45-year-old female client is admitted to the psychiatric unit for evaluation. Her husband states that she has been reluctant to leave home for the last six months. The client has not gone to work for a month and has been terminated from her job. She has not left the house since that time. This client is displaying symptoms of which 7. disorder? a. A 19-year-old female client with a diagnosis of anorexia nervosa wants to help serve dinner trays to other clients on a psychiatric unit. What action should the nurse 8. take? a. A female client with depression attends a group and states that she sometimes misses her medication appointments because she feels very anxious about riding the bus. Which statement is the nurse's best 9. response? a. A woman brings her 48-year-old husband to the outpatient psychiatric unit and describes his behavior to the admitting nurse. She states that he has been sleepwalking, cannot remember who he is, and exhibits multiple personalities. The nurse knows that these behaviors are often associated with which 10. condition? At the first meeting of a group of older adults at a day care center for the elderly, the nurse asks one of the members what kinds of things she would like to do with the group. The older woman shrugs her shoulders and says, "You tell me, you're the leader." What would be the best response for the nurse to 11. make? a. Over a period of several weeks, one male client participant of a socialization group at a community day care center for the elderly monopolizes most of the group's time and interrupts others when they are talking. What is the best action for the nurse to take in this 12. situation? a. A client in the critical care unit who has been oriented suddenly becomes disoriented and fearful. Assessment of vital signs and other physical parameters reveal no significant changes, and the nurse formulates the diagnosis: "Confusion related to ICU psychosis." Which intervention is best to implement based on this client's 13. behavior? a. A client on the psychiatric unit appears to imitate a certain nurse on the unit. The client seeks out this particular nurse and imitates her mannerisms. Which defense mechanism does the nurse recognize in this 14. client? a. A nurse working on a mental health unit receives a community call from a person who is tearful and states, "I just feel so nervous all of the time. I don't know what to do about my problems. I haven't been able to sleep at night and have hardly eaten for the past 3 to 4 days." The nurse should initiate a referral based on which 15. assessment? a. An anxious client expressing a fear of people and open places is admitted to the psychiatric unit. What is the most effective way for the nurse to assist this 16. client? a. Within several days of hospitalization, a client is repeatedly washing the top of the same table. Which initial intervention is best for the nurse to implement to help the client cope with anxiety related to this 17. behavior? a. The nurse is planning to initiate a socialization group for older residents of a long-term facility. Which information would be most useful to the nurse when planning activities for the 18. group? a. Which ego-defense mechanisms are exhibited by a client with a phobia related to refusal 19. to leave home? a. A client who has been admitted to the psychiatric unit tells the nurse, "My problems are so bad. No one can help me." Which response would be best for the nurse to 20. make? A 22-year-old male client is admitted to the emergency center following a suicide attempt. His records reveal that this is his third suicide attempt in the past two years. He is conscious, but does not respond to verbal commands for treatment. Which assessment finding should prompt the nurse to prepare the client for gastric 21. lavage? a. A 68-year-old retired secretary is admitted to the psychiatric inpatient unit with a diagnosis of major depression. The initial nursing care plan includes the goal, "Assist client to express feelings of guilt." What is true about the goal statement referring to the client's 22. depression? a. The nurse is planning care for a 32-year-old male client diagnosed with HIV infection who has a history of chronic depression. Recently, the client's viral load has begun to increase rather than decrease despite his adherence to the HIV drug regimen. What should the nurse do first while taking the client's history upon admission to the 23. hospital? a. The nurse admits a client with depression to the mental health unit. The client reports difficulty concentrating, losing 10 pounds in two weeks, and sleeping 12 hours a day. Which outcome is most important for the client to meet 24. by discharge? a. Which diet selection by a depressed client taking tranylcypromine sulfate (Parnate), an MAO inhibitor, indicates to the nurse that the client understands the dietary restrictions imposed by this medication 25. regimen? a. A 72-year-old female is admitted to the psychiatric unit with a medical diagnosis of major depression. Which statement by the client would be of greatest concern to the nurse and would require further 26. assessment? A 33-year-old is admitted to a Psychiatric facility with a medical diagnosis of major depression. When the nurse is assigning the client to a room, which roommate is best for this 27. client? a. A client is admitted with a diagnosis of depression. The nurse knows that which characteristic is most indicative of 28. depression? a. A 22-year-old female is admitted to the psychiatric unit from the medical unit following a suicide attempt with an overdose of diazepam (Valium). When developing the nursing care plan for this client, what intervention would be most important to 29. include? A female client in an acute care facility has been on antipsychotic medications for the past three days. Her psychotic behaviors have decreased and she has had no adverse reactions. On the fourth day, the client's blood pressure increases, she becomes pale and febrile, and demonstrates muscular rigidity. What action should the nurse 30. initiate? a. A 27-year-old female is admitted to the psychiatric hospital with a diagnosis of bipolar disorder, manic phase. She is demanding and active. What intervention should the nurse include in this client's plan of 31. care? a. A manic depressive male client on the psychiatric unit becomes loud, and shouts at one of the nurses, "You fat tub of lard, get something done around here." What is the best initial action for the nurse to 32. take? a. A 45-year-old male client tells the nurse that he used to believe that he was Jesus Christ, but now he knows he is not. Which response is best for the nurse to 33. make? a. A 38-year-old woman is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her room, she refuses to eat and tells the nurse, "I know you are trying to poison me with that food." What response by the nurse is the most 34. therapeutic? A 35-year-old male client admitted to the psychiatric unit of an acute care hospital tells the nurse that he believes someone is trying to poison him. The client's delusions are most likely related to which 35. factor? a. A 35-year-old male client who has been hospitalized for two weeks for paranoia complains continuously to the staff that someone is trying to steal his clothing. What is the correct action for the nurse to take based on this client's 36. complaints? An 86-year-old female client with Alzheimer's disease is wandering the busy halls of the extended care facility and asks the nurse, "Where should I stand for the parade?" Which response is best for the nurse to 37. provide? a. The nurse is planning discharge for a male client with schizophrenia. The client insists that he is returning to his apartment, although the physician informed him that he will be moving to a boarding home. What is the most important nursing diagnosis for discharge 38. planning? A client who is diagnosed as schizophrenic is admitted to the hospital. The nurse assesses the client's mental status. Which assessment finding is most characteristic of a client with 39. schizophrenia? a. On admission, a highly anxious client is described as delusional. The nurse understands that delusions are most likely to occur with which 40. disorder? a. A 25-year-old female client has been particularly restless and the nurse finds her trying to leave the psychiatric unit. She tells the nurse, "Please let me go. I must leave because the secret police are after me." What response is best for the nurse to 41. make? a. A client who is being treated with lithium carbonate for manic depression begins to develop diarrhea, vomiting, and drowsiness. What action should the nurse 42. take? a. A male schizophrenic client, taking fluphenazine deconate (Prolixin deconate), is being discharged in the morning. A repeat dose of medication is scheduled for 20 days after discharge. The client tells the nurse that he is going on vacation and will return in 18 days. Which statement by the client indicates a need for health 43. teaching? An adult client with a medical diagnosis of substance abuse and schizophrenia was recently switched from oral fluphenazine HCl (Prolixin) to IM fluphenazine decanoate (Prolixin Decanoate) because of medication noncompliance. What is important to teach the client and family about this change in medication 44. regimen? a. The nurse develops a plan of care for a client with symptoms of paranoia and psychosis. The priority nursing diagnosis is "Impaired social interactions related to inability to trust." Which intervention is most important for the nurse to 45. implement? The nurse is conducting discharge teaching for a client who has schizophrenia and plans to live in a group home. Which statement is most indicative of the need for careful follow-up after 46. discharge? a. An 8-year-old child is seen in the clinic with a green vaginal discharge. What action is most important for the nurse to 47. implement? a. Clients are preparing to leave the mental health unit for an outdoor smoke break. A client on constant observation cannot leave and becomes agitated and demands to smoke a cigarette. What action should the nurse take 48. first? a. The nurse collaborates with the nursing staff about the plan of care for a client who is very depressed. What is the most important intervention to implement during the first 48 hours of 49. hospital admission? a. The charge nurse collaborates with the nursing staff members about the plan of care for a client who is depressed. What is the most important intervention to implement during the first 48 hours after the client's admission to the 50. unit? a.