MENTAL HESI 2 LATEST 2021 100% VERIFEID

A male employee who is assessed weekly in the employee clinic for blood pressure because of a history of hypertension tells the nurse that he is so upset with one of his co-workers that he would like to shoot him. What action should the nurse take first? 1. a.) A male client who is participating in an anger management assignment asks if he can make a leather belt in occupational therapy. The client begins pounding the leather vigorously with a mallet to imprint designs on the belt. What defense mechanism is the client 2. using? A 20-year-old female client with schizophrenia is scheduled to receive risperidone (Risperdal) 2mg at bedtime. When the nurse attempts to administer the medication, the client states. “I am not going to take that medicine, and you can’t make me.” What action should the nurse 3. take? An adult female client tells the nurse that though she is afraid her abusive boyfriend might one day kill her, she keeps hoping that he will change. What action should the nurse 4. take first? A male client with bipolar disorder has not slept or eaten in four days. He paces and becomes increasingly agitated and loud while the nurse talks to his spouse. What intervention is the best for the nurse to implement at this 5. time? The nurse asks a female client with a borderline personality disorder, “How do you feel about your children not coming to visit this weekend?” The client looks out the window and replies, “I really don’t care.” Which response is best for the nurse to 6. provide? What is the most important goal of care for a client diagnosed with generalized anxiety disorder (GAD) who has been taking the benzodiazepine alprazolam (Xanax) long-term? The client 7. will The nurse is performing intake interviews at a psychiatric clinic. A female client with a known history of drug abuse reports that she has a heart attack four years ago. Use of which substance abuse places the client at highest risk for myocardial 8. infarction. During a one-to-one session with the nurse, a female client who has been admitted for chronic depression and attempted suicide discloses her experience of sexual promiscuity and prostitution. When the nurse asks the client if she was ever sexually abused as a child, the client says, “I don’t remember, but my mother ran my father off when I was five.” The nurse should recognize that the client may be using which defense 9. mechanism? A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words and wanders into client’s room. The nurse decides that the client needs constant observation based on which of these assessment 10. findings? A women is brought to the psychiatric clinic by her husband who reports that his wife is reluctant to leave home because of what she describes as fear of open places and crowds. What is the best nursing diagnosis for this 11. client? The atypical antipsychotic ziprasidone (Geodon) is prescribed for a client with a medical diagnosis of schizophrenia. After the client has been taking the medication for two weeks, the nurse assesses the drug’s effectiveness. Which client report suggests that the medication is 12. helpful? A male college student brings his roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that the voices are saying, “kill kill.” What question should the nurse ask the client 13. next? A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone (Risperdal). When the client walks to the nurse’s station in a laterally contracted position, he states that something has made his body contort into a monster. What action should the nurse 14. take? The nurse on the evening shift received report that a client is scheduled for electroconvulsive treatment (ECT) in the morning. Which interventions should the nurse implement the evening before the scheduled 15. ECT? During the initial nursing interview, a client tells the nurse, “Sometimes my thoughts go so fast. Wonder if I can sell my fast car. Work is so boring. I wonder if I can get a transfer. Is it time to eat yet?” Which documentation should the nurse use to describe the client’s 16. statements? A chronically depressed older male resident of a long-term care facility has become more reclusive and today refuses to leave his room. His family moved away from the local area and they are unable to visit as much as they had in the past. Which comment by the nurse is like to be most helpful to 17. this client? A client with borderline personality disorder tells the nurse, “You are the best nurse on the unit! The other nurses don’t care about me the way you do.” Which response is best for the nurse to provide this 18. client? A male client who is admitted with bipolar disorder( manic psychosis), is placed in seclusion after unsuccessful attempts to de-escalate him during a sudden mood swing from laughter to jumping and screaming threats while having a plastic dinner knife. The client is given haloperidol (Haldol) 5 mg IM STAT prior to seclusion. What intervention is most important for the nurse to implement immediately after 19. seclusion? The nurse notes that a depressed female client has been more withdrawn and no communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this 20. client? A young adult male client is admitted to the psychiatric unit because of recent suicide attempt. His wife filed for divorce six months ago, he lost his job three months ago, and his best friend moved to another city two weeks ago. Which intervention should the nurse include in the client’s plan of 21. care? A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. What action should the nurse 22. implement? The nurse is admitting a male client who takes lithium carbonate (Eskalith) twice a day. Which information should the nurse report to the healthcare provider immediately? A young female client is admitted to the emergency room because she was raped that evening by her date. How should the nurse record the client’s chief complaint in the medical 23. record? An older female adult who lives in a nursing home is loudly demanding that the nurse call her son who has been deceased for five years. Which intervention should the nurse 24. implement? A teenaged male client is admitted to the postoperative unit following open reduction of a fractured femur which occurred when he fell down the stairs at a party. The nurse notices needle marks on the client’s arms and plans to observe for narcotic withdrawal. Early signs of narcotic withdrawal include which assessment 25. findings? Two days after his last drink, a male alcoholic client becomes agitated, and yells at his wife and children, “Stay away from me!” His vital signs are elevated. What nursing diagnosis has the highest 26. priority? The nurse interacts with a male client who is very depressed and slow to respond to questions. The nurse asks the client to explain how he is feeling, but the client looks down at the table. What action would be best for the nurse to 27. implement? A 15-year-old male with mild mental retardation is admitted to the adolescent unit because he repeatedly refuses to complete personal hygiene. The healthcare provider prescribes that the client brush his teeth three times a day. In the psychiatric team conference, a behavior modification program is recommended to engage the client’s participation. When implementing this technique, what reinforcement is best for the nurse 28. to provide? When developing a plan of care for a client to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing diagnosis has the highest 29. priority? A female client with obsessive-compulsive personality disorder is admitted to the hospital for a cardiac catheterization. The afternoon before the procedure, the client begins to keep detailed notes of the nursing care she is receiving, and reports her findings to the nurse at bedtime. What action should the nurse 30. implement? A young adult female client is admitted to a psychiatric facility with a medical diagnosis of bulimia nervosa. Which nursing intervention has the highest priority? Which client information indicates the need for the nurse to use the CAGE questionnaire during the admission 31. interview? An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days. Which assessment finding requires immediate 32. follow-up? The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. What information should the nurse explore in depth with the client based on this screening tool? A teenaged client, a heroin addict, is admitted to the unit for detoxification. What intervention is most important for the nurse to initiate during the first 24 hours after 33. admission? A client is admitted to the mental health unit for feelings of depression secondary to a positive HIV report. To provide a safe milieu for this client, what action should the nurse 34. take? The nurse documents that a male client with paranoid schizophrenia is delusional. Which statement by the client confirms this 35. assessment? A male client turns over a table in the dayroom of a psychiatric unit and threatens to throw a chair at another client. Which action is most important for the nurse to 36. implement? A client is admitted to the mental health unit with a diagnosis of adjustment disorder and depressed mood. Findings of which diagnostic tests provide the most information for developing this client’s plan of 37. care? The client is being admitted to the psychiatric unit for depression and self-deprecation. Which intervention should the nurse implement 38. first? An 8-year-old client is brought to the emergency department with a suspected drug overdose. Which information is most important for the nurse to obtain from the 39. family? The nurse is assess a male client with paranoia. Which behavior can this client be expected 40. to? a) The nurse completes a health assessment for a client a long alcohol dependency at health finding is the client most likely to 41. report? a) A client postpartum depression receive prescription Sertraline (Zoloft). What information is most important to include in 42. client teaching? A) When communicating a client Bipolar disorders , the nurse realizes that the client is suddenly becoming tense and verbally abusive. What action should the nurse 43. take? a)