HESI MENTAL HEALTH PRACTICE QUIZ 3

HESI MENTAL HEALTH PRACTICE QUIZ 3 Psychiatric B 1. 1.ID: 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 improved self-esteem? o Identifies own strengths. Correct o Asks the nurse if her behavior has improved. o Talks with other clients about marital advice. o Stops crying during every session. Identifying one's personal strengths (A) is an important part of increasing self-esteem. Crying during sessions with the nurse or other members of the healthcare team is a sign of depression or sadness, and (B) does not indicate an improved self-esteem. Talking with peers about marital advice (C) implies a lack of confidence in decision-making. Asking the nurse if one's behavior is improving (D) indicates a need for reassurance. Awarded 5.0 points out of 5.0 possible points. 2. 2.ID: 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 first? o Administer a PRN dose of haloperidol (Haldol) IM. o Encourage the client to focus on his feelings of anger. o Place the client in mechanical restraints until calm. Correct o Use a calm, soothing voice to diffuse the situation. This client is demonstrating behaviors that may be a danger to himself or others, and in such an emergency situation, restraints may be applied by an authorized staff member (A). (B) may pose a danger to the staff. This client is experiencing distorted sensory perceptions, so he is unlikely to respond to (C) or have the ability to verbalize his feelings (D). Category: Psychiatric Mental Health Awarded 5.0 points out of 5.0 possible points. 3. 3.ID: Which client should the nurse identify as the highest risk for the onset of stress-related problems? o 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. o 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 o 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. o 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. 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. Awarded 5.0 points out of 5.0 possible points. 4. 4.ID: 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? o Cannot mentally retrace objects that were recently misplaced. Correct o Repeats the same stories to different family members or friends. o Cannot remember instructions to program an electronic device. o 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. Awarded 5.0 points out of 5.0 possible points. 5. 5.ID: The nurse is caring for an adult male client with catatonic schizophrenia who is mute and motionless. What is the priority nursing diagnosis? o Impaired mobility. Incorrect o Ineffective individual coping. o Impaired verbal communication. o High risk for fluid and electrolyte imbalance. Correct Maintaining physiological stability by first addressing basic physiological needs is the priority. A client who is in a catatonic or stuporous state is at risk for malnutrition and/or dehydration, so risk for fluid and electrolyte imbalance (D) is the priority nursing diagnosis for this client at this time. Lack of mobility (A) is related to psychomotor retardation rather than to physical limitations, and is not life-threatening. The client's mute state (C) and ineffective individual coping (B) can be addressed later in treatment. Awarded 0.0 points out of 5.0 possible points. 6. 6.ID: 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? o Increased serum creatinine level. o Elevated serum calcium level. o Positive rapid plasma reagin (RPR). o Increased thyroid stimulating hormone (TSH). Correct 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. Awarded 5.0 points out of 5.0 possible points. 7. 7.ID: The nurse asks an older female client with cognitive impairment who has been hospitalized for three days how her previous evening was. The client replies, "I had the best time." My husband took me out to dinner and then to a concert. The music was wonderful. Which term should the nurse document to best describe the client's response? o Concretization. o Delusions. Incorrect o Confabulation. Correct o Circumstantiality. Confabulation (B) describes the client's story that is made-up to fill in the gaps of memory when one is unable to remember something that might have happened. (A) is a manifestation of a false belief. (C) is the inability to abstract with overemphasis on detail. (D) is a disturbance in thought that provides discussion in an excessive amount of detail that is often tangential or irrelevant. Category: Psychiatric Mental Health Awarded 0.0 points out of 5.0 possible points. 8. 8.ID: 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 apply.) o Created extensive private property damage. o Threats to kill his friend. Correct o Says he has not eaten in 3 days. Correct o Reports he has not needed a bath in 4 months. Correct o Disruptive behaviors in a community setting. o Hears voices telling him to kill himself. Correct Correct responses are (A, C, D, and F). Most states provide for emergency involuntary hospitalization or civil commitment for a specified period to prevent dangerous behavior that is likely to cause harm to self or others. Police officers and healthcare providers may be designated by statute to authorize the detention of persons who are a danger to themselves or others (A and C) or who are unable to provide for their own basic needs (D and F) due to mental illness. (B and E) are civil issues, not factors related to involuntary commitment. Awarded 5.0 points out of 5.0 possible points. 9. 9.ID: 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? o What do you think the hospital can do for you? o We are all here to help you get better. o How long have you felt this way? o 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. Awarded 5.0 points out of 5.0 possible points. 10. 10.ID: 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? o Search the client's personal belongings. Correct o Move to a room that allows close observation. o Introduce the client to others on the unit. o Ask the client about recent stressful events. 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. Awarded 5.0 points out of 5.0 possible points. 11. 11.ID: Which client statement should the nurse identify as most typical of a client with mania? o I wonder why my wife is so upset that I spend money easily. o I can't do anything anymore. o I manage our finances great because I buy in big quantities. Correct o I can't understand where all our money goes. A client with bipolar disorder, mania, characteristically demonstrates thoughts of inflated self-esteem, grandiosity, and a tendency for excessiveness, such as excessive spending (C). (A) is a statement of dispair that is more likely made by a client with depression. Although a client with mania may lack insight (B) regarding the impact that excessive, bizarre behaviors have on the lives around them (D), the diagnostic criteria that hallmarks mania is excessive involvement in pleasurable activities with painful consequences. Awarded 5.0 points out of 5.0 possible points. 12. 12.ID: 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? o Introduce the client to others on the unit. o Move to a room that allows close observation. o Ask the client about recent stressful events. o Search the client's personal belongings. Correct 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. Awarded 5.0 points out of 5.0 possible points. 13. 13.ID: 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 nurse implement? o Escort the client to a quieter place. Correct o Ignore the client's manic outbursts. o Ask the group to reconsider the suggestion. o Tell the client to quiet down. A client in the manic phase has an inflated ego, feelings of grandiosity, and is unlikely to respond to limit-setting. To curtail further escalation and disruption, the client should be escorted to a less stimulating environment (B). (A) is ineffective because a client in the manic phase is often unable to control their behavior. The group decision should be supported, not (C). Ignoring the client's outbursts (D) frequently leads to escalation of the behaviors and increases the client's risk of self-injury or injury of others. Awarded 5.0 points out of 5.0 possible points. 14. 14.ID: Which action should the nurse implement first for a client experiencing alcohol withdrawal? o Prepare the environment to prevent self-injury. Correct o Give an alpha-adrenergic blocker. o Provide a diet high in protein and calories. o Apply vest or extremity restraints. Self-destructive or violent behavior provides a potentially immediate and life-threatening risk to the client and others, so a safe environment should be provided (D) by removing any potential objects that could inflict self-injury. Secondary prevention strategies (frequent orientation to surroundings, restraints to prevent self-injury (A), and the administration of antianxiety agents or alpha-adrenergic blockers (B) for hallucinations, delusions, confusion, and agitation) should then be implemented. Once the client is stabilized, nutritional issues (C) should be addressed. Awarded 5.0 points out of 5.0 possible points. 15. 15.ID: 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? o Prepare the child for cast placement. o Evaluate the intellectual functioning of the child. o Ask the child to explain the accident. o Evaluate the child for other injuries. Correct 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. Awarded 5.0 points out of 5.0 possible points. 16. 16.ID: 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? o Reassure the husband that his wife will be treated well while he is in the waiting area. o Notify the local police of a suspected spousal abuse situation. o Require the husband to leave the cubicle while the client is being treated. Correct o Ask the hospital security to remove the husband from the treatment room. 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. Awarded 5.0 points out of 5.0 possible points. 17. 17.ID: A client with severe depression tells the nurse, "I do not know why you bother with me or give me pills. I am never going to get well." What is the most therapeutic response? o I have known many clients with depression who have felt better after several weeks of treatment. Correct o You are feeling very pessimistic, but that is part of your illness. It should go away as you recover. o You are no bother to me or to the staff. We want you to get well and not feel sad anymore. Incorrect o You need to stop thinking negative thoughts. They get in the way of your recovery. Stating the observation that others have recovered can give a client hope (C). (A) is ineffective because the client must be taught cognitive strategies to stop negative thinking. (B) is arguing with the client's beliefs and attempting to tell him how to feel, both of which are not therapeutic responses. (D) interprets the client's feelings and does not provide the same degree of hope. Category: Psychiatric Mental Health Awarded 0.0 points out of 5.0 possible points. 18. 18.ID: 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? o You are likely to have a difficult time staying sober if you think that your problems with alcohol are behind you. o Yes, the treatment program you attended has an excellent success profile. o Can you tell me more about what you mean when you say that your problems with alcohol are now behind you? Correct o 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. Awarded 5.0 points out of 5.0 possible points. 19. 19.ID: 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? o Encourage the client to stop pacing and sit down. o Review the client's baseline blood pressure. o Reevaluate the client's blood pressure in an hour. Correct o Direct the client to attend recreational therapy. 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. Awarded 5.0 points out of 5.0 possible points. 20. 20.ID: 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 process? o I know now that I wasn't ready to make a change until I hit rock bottom. o A 12-step program is the only treatment approach that is proven effective. o By learning what led to my latest relapse, I know what to do in the future. Correct o I do OK as long as I can get methadone from the clinic regularly. Recovery is a lifelong process in which clients must constantly learn and apply new behaviors to replace ineffective ones. Every attempt toward recovery improves long-term chances of success, so those who learn from their relapses demonstrate an understanding of the process (B). Methadone treatment is not indicated for all substance abusers, only those addicted to opiates, and enrollment in this type of program does not necessarily mean that the client is committed to recovery (A). While 12-step programs are known to work, there are many other effective treatment approaches (C). Client readiness is highly individualized, and can stem from a variety of experiences and situations, so hitting rock bottom is not necessary before clients can attempt recovery (D). Awarded 5.0 points out of 5.0 possible points.