2022/2023 Module 4 Exam_ HESI VN (LATEST Questions And Answers)

7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Question 1 1 / 1 pts A client with schizophrenia says, “I’m away for the day ... but don’t think we should play … or do we have feet of clay?” Which alteration in the client’s speech does the nurse document? Neologism Word salad Correct! Clang association Associative looseness Rationale: Clang association is the meaningless rhyming of words in which the rhyming is more important than the context of the words. A neologism is a made-up word that has meaning only to the client. Word salad is the term for a mixture of meaningless phrases, either to the client or to the listener. Associative looseness is a term used to describe schizophrenic speech in which connections and threads are interrupted or missing. Test-Taking Strategy: Knowledge of the speech patterns exhibited by the client with schizophrenia is needed to answer this question. Focus on the data in the question and note the meaningless rhyming of words. Review these speech patterns with schizophrenia if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Question 2 1 / 1 pts 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) A client with schizophrenia and his parents are meeting with the nurse. One of the young man’s parents says to the nurse, “We were stunned when we learned that our son had schizophrenia. He was no different than from his older brother when they were growing up. Now he’s had another relapse, and we can’t understand why he stopped his medication.” Which response by the nurse is appropriate? Telling the parents, “Medication noncompliance is the most frequent reason that people with this diagnosis relapse.” Telling the parents, “Well, it’s his decision to take his medicine, but it’s yours to have him live with you if he stops the medication.” Asking the client, “How can we help you to take your medicine or to tell us when you’re having problems so that your medication can be adjusted?” Correct! Saying to the parents, “Your concerns are appropriate, but I wonder whether your son was having trouble telling someone that he had concerns about his medication.” 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: The therapeutic response is the one in which the nurse models speaking directly to the client. This facilitates further assessment of the situation and helps elicit the causes of and motivations for the client’s behavior for both the nurse and the family. In the correct option, the nurse also seeks clarification of the degree of openness and mutuality felt by the client and his family toward each other. The nurse provides information to the family when stating that noncompliance is the most frequent reason for relapse in people with this diagnosis. However, the statement is nontherapeutic at this time because it does not facilitate the expression of feelings. The nurse uses a superego style of communication when stating, “Well, it’s his decision to take his medicine, but it’s yours to have him live with you if he stops the medication.” The content of this statement may be true, but it is nontherapeutic in that it carries a threatening message and may prevent the family from trusting the nurse. By stating “Your concerns are appropriate, but I wonder whether your son was having trouble telling someone that he had concerns about his medication,” the nurse gives approval and prematurely analyzes the client’s motivation without sufficient assessment. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques and remember to focus on the client’s feelings. Also note that the correct option is the only option in which the nurse directly addresses the client. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Question 3 1 / 1 pts An acutely ill client with schizophrenia says to the nurse, “He keeps saying that he likes you, and I keep telling him you’re married, but he won’t listen, and I think he’s going to get fresh with you.” Once the nurse has determined that the client is 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) hallucinating, which response to the client would be most appropriate statement? “Try not to listen to the voices right now so that I can talk with you.” Correct! “I think that you can help him stop his behavior if you concentrate.” “Tell him I said to mind his p’s and q’s or I’ll call the police on him.” “I think that you’re trying to share your own feelings toward me, but you’re shy.” Rationale: The appropriate statement by the nurse is the one that does not acknowledge the client’s hallucinations. By responding “I think that you can help him stop his behavior if you concentrate” or “Tell him I said to mind his p’s and q’s or I’ll call the police on him,” the nurse acknowledges the hallucinations. The nurse attempts to interpret the client’s thinking with a statement such as “I think that you’re trying to share your own feelings toward me, but you’re shy.” Test-Taking Strategy: Use your knowledge of therapeutic communication techniques and remember that the nurse should not acknowledge the client’s hallucinations. Also note that the correct option is the only one that encourages realistic verbalization from the client. Review therapeutic communication techniques with a client who is hallucinating if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Question 4 0 / 1 pts A client says to the nurse, “It’s over for me—the whole thing is over.” Which response by the nurse would be therapeutic? You Answered “What do you mean, ‘The whole thing is over’?” “Over? Well, that sounds pretty drastic to me. Let’s discuss this in the strictest confidence.” “Can you tell me more about why it’s over for you? I’ll keep your thoughts strictly confidential.” “Let’s talk more about your feeling that the whole thing is over for you. This is important, and I may need to share your feelings with other staff members.” Correct Answer 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: The therapeutic response seeks clarification, employs paraphrasing, and informs the client that the nurse needs to share any information that requires crisis intervention with other staff members. Asking “What do you mean, ‘The whole thing is over’?” employs paraphrasing, but the message is blunt and closed-ended. In stating “Over? Well, that sounds pretty drastic to me. Let’s discuss this in the strictest confidence,” the nurse uses hysterical exaggeration (at an inappropriate time) and gives incorrect information regarding confidentiality. In stating “Can you tell me more about why it’s over for you? I’ll keep your thoughts strictly confidential,” the nurse uses the therapeutic technique of seeking clarification but does not clarify with the client that the information might need to be shared. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that indicate that shared information will be maintained as confidential. To select from the remaining options, focus on the statement that addresses the client’s feelings. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Communication and Documentation Content Area: Mental Health Question 5 1 / 1 pts A nurse performing a lethality assessment asks the client whether he is thinking of suicide. Which statement by the client would be of most concern to the nurse? Correct! “No, I wasn’t, but I am now, thanks to you.” “I hadn’t thought of that, but I can see that you are.” “Of course not, but there are days when I think that I should be.” 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) “What is suicide going to do for me except get me excommunicated from the church?” Rationale: The client’s response that he is now thinking about suicide is of the greatest concern to the nurse. In making the statement “I hadn’t thought of that, but I can see that you are” the client projects his own thoughts of suicide onto the nurse. In stating “Of course not, but there are days when I think that I should be,” the client is being sarcastic but is not specifically talking about suicide. In stating “What is suicide going to do for me except get me excommunicated from the church?” the client indicates that suicide is not an option because of his religious beliefs. Test-Taking Strategy: Use the process of elimination and note the strategic words “of most concern to the nurse.” Note the words “but I am now” in the correct option. This is the only option that identifies definite suicidal thoughts. Review lethality assessment in the suicidal client if you had difficulty with this question. Cognitive Ability: Analyzing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Assessment Content Area: Mental Health Question 6 1 / 1 pts A client who has expressed suicidal ideation in the past says to the nurse, while shuffling several documents in an effort to organize them, “Well, I’m feeling so much better now since I got organized. My lawyer wrote my will and durable power of attorney.” Which response by the nurse is appropriate? “Good grief! You don’t look organized to me.” 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) “Okay, what are you up to today? Your behavior is not appropriate.” “You talk about getting organized. Are you thinking of killing yourself?” Correct! “If you keep behaving like this, you know that I’ll have to tell the doctor, and we’ll have to seclude you.” Rationale: The client is exhibiting behaviors that indicate plans for suicide. Talking of suddenly “feeling so much better” and putting affairs in order are key verbal and behavioral clues that the client is planning to commit suicide. In exclaiming “Good grief! You don’t look organized to me,” the nurse nontherapeutically uses hysterical exaggeration, which minimizes the client’s feelings. In asking “Okay, what are you up to today? Your behavior is not appropriate,” the nurse uses teasing to determine the client’s behaviors, which minimizes them. Additionally, the nurse is employing a nontherapeutic technique of judging. In stating “If you keep behaving like this, you know that I’ll have to tell the doctor and we’ll have to seclude you,” the nurse uses a threat. Test-Taking Strategy: Use the process of elimination. Focus on the information in the question and note the relationship between the words “expressed suicidal ideation” in the question and “thinking of killing yourself” in the correct option. Review the clues that indicate the potential for suicide if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Communication and Documentation Content Area: Mental Health Question 7 1 / 1 pts 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) An adolescent client says, “I’m just a burden to my folks. They wish I’d never been born. My dad told me he had to marry Mom because she got pregnant.” Which response by the nurse would be therapeutic? “You’re feeling that your folks didn’t want you, but they chose to marry and have you.” Correct! “You feel that you were a burden and not wanted? Let’s talk with your parents to see whether you’re right.” “Let’s speak with your parents about what you’ve just told me. Let’s ask whether you were truly unwanted.” “Sounds like your father was very inappropriate, but I’m certain that he didn’t mean that you were a burden to him.” 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: In the correct option, the nurse uses reflection to explore the client’s lethality risk and then uses reframing to determine whether the client is able to view what happened in a different way. In suggesting “You feel that you were a burden and not wanted? Let’s talk with your parents to see whether you’re right,” the nurse uses paraphrasing but is then nontherapeutic in trying to persuade the client to talk to the parents. In suggesting “Let’s speak with your parents about what you’ve just told me. Let’s ask whether you were truly unwanted,” the nurse uses a parental approach, which may be threatening to the client, who seems to have been unable to talk with the parents before now. In stating “Sounds like your father was very inappropriate, but I’m certain that he didn’t mean that you were a burden to him,” the nurse offers an opinion about the client’s father and then provides false reassurance. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that address discussing the client’s feelings with the parents. In selecting from the remaining options, remember to focus on the client’s feelings. Select the option that exemplifies therapeutic communication technique. This will direct you to the correct option. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Question 8 1 / 1 pts A client says to the nurse, “I’ve ruined my life. I left college with only a few credits to go. I keep telling myself that I’m going to make it as a writer, but I’ll be a loser and a nothing for the rest of my life.” Which response by the nurse is therapeutic? “What are you saying? Sounds like you need to pull yourself together and go back to school.” 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) “Having faith in yourself is one thing, but looking at your alternatives realistically is another.” “You seem to be saying that your choices are final and that you’ve lost any other opportunities.” Correct! “Sounds like you feel that things should come easy for you, unlike the rest of us, who work for what we get.” Rationale: The client in this question is engaging in catastrophizing rather than reframing and viewing other alternatives. The task for the nurse is to assess the client’s situation and to help the client feel empowered to take another course of action and find the perseverance and confidence to do so. The therapeutic response here is the one that is nonjudgmental. In responding “What are you saying? Sounds like you need to pull yourself together and go back to school,” or “Sounds like you feel that things should come easy for you, unlike the rest of us, who work for what we get,” the nurse communicates with the client as a parent, using a judging style. In stating “Having faith in yourself is one thing, but looking at your options realistically is another,” the nurse communicates prematurely and gives advice. Test-Taking Strategy: Use the process of elimination and your knowledge of therapeutic communication techniques. Eliminate the comparable or alike options that demonstrate the nurse using a judging style to deal with the client. To select from the remaining options, eliminate the option that is nontherapeutic in that the nurse gives advice. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Question 9 1 / 1 pts A client who has twice attempted suicide says, “If people would just leave me alone and let me do what I want with my life, I could get on with what I want to do.” Which response should the nurse should give to the client? “Of course you can’t be left alone to get on with what you want to do.” “Okay, go ahead and do whatever you want to do. Human beings have free will.” “You’ve tried to end your life twice, yet you feel that everyone should let you do what you want to do?” Correct! “Sounds like you’re angry with people for caring enough about you to try to keep you from hurting yourself.” 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: The therapeutic response is the one that offers reflection, which permits the client to observe the content of what she is saying. In stating “Of course, you can’t be left alone to get on with what you want to do,” the nurse makes a response that is social and belittles the client’s feelings. In stating “Okay, go ahead and do whatever you want to do. Human beings have free will,” the nurse makes a response that seems sarcastic and angry; it is also judgmental and biased. In stating “Sounds like you’re angry with people for caring enough about you to try to keep you from hurting yourself,” the nurse makes a premature judgment. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. The correct option is the only response that is therapeutic in that it uses reflection. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Communication and Documentation Content Area: Mental Health Question 10 1 / 1 pts A homeless client with an antisocial disorder is brought to the emergency department by the police after disturbing customers in a department store. The client says to the nurse, “I need to be hospitalized. It’s getting cold out, and I need a warm bed. If you don’t get me into a hospital, I’ll jump off a bridge.” Which nursing intervention would be therapeutic? Sending the client to the psychiatric hospital intake center immediately for evaluation Asking the police to pick the client up and arrest him for vagrancy, as they should have done immediately 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Discharging the client with a follow-up appointment for the next day and guaranteeing him a hospital bed if he shows up Sending the client to a shelter that will provide temporary housing if he signs a contract agreeing not to attempt suicide Correct! Rationale: The client is clearly using suicide as a threat so that he will be hospitalized. As long as self-harm is not an issue, providing the client with shelter will meet his needs. Sending the client to the psychiatric hospital intake center immediately for evaluation is an intervention that should be used if the client refuses to sign a contract for “no suicide.” Guaranteeing the client a hospital bed if he shows up for a follow-up appointment is manipulation, which is a nontherapeutic intervention. The nurse would not order the police to arrest a client. Test-Taking Strategy: Use knowledge of the subject, selfharm issues, to assist you with the process of elimination. Eliminate the option that indicates arresting the client, because it is not the nurse’s role to determine who requires arrest by the police. Next eliminate the option that involves manipulation. From the remaining options, select the option that provides the client shelter and addresses the risk of self-harm. Review self-harm issues and the appropriate nursing interventions if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Mental Health Question 11 1 / 1 pts A client is admitted to the medical-surgical unit of a hospital, and suicide precautions are taken until the client can be admitted to the psychiatric unit. Which nursing intervention does the nurse implement? 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Placing the client in a private room and locking the client’s closets and bathroom Placing the client in a private room and removing all knives and glass from the client’s meal tray Allowing the client to go out on pass as long as the client is accompanied by a responsible adult Placing the client in a semiprivate room, providing plastic utensils for eating, and keeping an arm’s distance from the client at all times Correct! Rationale: When a client is suicidal, someone must be at arm’s length at all times, observing the client, and the client must be in view at all times, even while toileting and showering. Plastic utensils are used for eating. A semiprivate room is better than isolation in a private room. Searching the client and the client’s room for harmful objects is done openly and randomly. Glass mirrors are removed and the bathroom is harm-proofed by replacing the metal shower curtain rod with a plastic rod that falls when 50 pounds of pressure is placed on it. Off-unit passes are not issued when a client is suicidal. Test-Taking Strategy: Use the process of elimination and focus on the subject, suicide precautions. Eliminate the options that are comparable or alike and involve the provision of a private room, because this environment further isolates the client. Next recall that a suicidal client would not be allowed off the nursing unit. Review suicide precautions if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Mental Health 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Question 12 1 / 1 pts A client is admitted to the psychiatric inpatient unit and suicide precautions are instituted. Which intervention does the nurse implement? Restricting visitors Placing the client in a private room and locking the bathroom door Removing perfume, shampoo, and other toiletries from the client’s room Correct! Placing flowers brought to the client in a small glass vase and putting them in the client’s room Rationale: When suicide precautions are instituted, all of the client’s belongings that are potentially harmful are removed and placed in a locked area from which the nursing staff can retrieve them as the client needs to use them. Visitors are not restricted. However, any items that a visitor brings to the client must be checked by the nurse. Glass items are not placed in the suicidal client’s room. Test-Taking Strategy: Use the process of elimination and focus on the subject, suicide precautions. Eliminate the option that is a violation of client rights; the client is allowed to have visitors. Next eliminate the options that contain the words “private room” and “glass.” Review suicide precautions if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Mental Health 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Question 13 1 / 1 pts A client who is undergoing psychiatric counseling calls a nurse on a hotline crying and states, “My priest assaulted me when I was an altar boy, and my dad just found out. He’s got a gun, and he’s driving over to the church rectory. I don’t know what to do.” Which response by the nurse is most appropriate initially? “How did your dad learn of your abuse by clergy?” “Call the police immediately and then call the priest to warn him that your dad has a gun.” “Call the priest immediately and tell him to lock the doors until the police arrive. I’ll call the police.” Correct! “You will want to come in to see our psychiatrist with your father, but for now, call the police and tell them what happened.” 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: Usually the volunteers on hotlines are trained to keep the client on the line, but in this case, the duty to warn the priest of the danger he is facing is paramount. When violence erupts, the nurse must think and act quickly and with clarity. “How did your dad learn of your abuse by clergy?” is off focus and inappropriate to the situation. Telling the client “Call the police immediately and then call the priest to warn him that your dad has a gun” is incorrect because the priest should be warned first. In stating “You will want to come in to see our psychiatrist with your father, but for now, call the police and tell them what happened,” the nurse does not focus on the imminent violence described in the question. Test-Taking Strategy: Note the strategic words “initially.” Eliminate the comparable or alike options that direct the client to call the police first. To select from the remaining options, consider the seriousness of the situation. This will direct you to the correct option. The priest needs to be warned of the danger. Review nursing responsibilities in violent situations if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Mental Health Question 14 0 / 1 pts A nurse determines that a client whose son died in a car accident is at risk for self-harm. Which intervention is most appropriate initially? Correct Answer Making a “no suicide” contract with the client Telling the client that anger should be suppressed Providing a peaceful place for the client to meditate You Answered Helping the client control expression of his feelings 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: The nurse would first plan to implement a “no suicide” contract when a client is at risk for self-harm. The safety of the client is the priority. The nurse would encourage the client to express angry, hostile feelings, not suppress them. Providing a peaceful place for the client to meditate is incorrect because the nurse would not want the client to isolate himself. Rather, the nurse would promote social interaction for the client. The nurse would help the client express (not control expression of) feelings that are painful. Test-Taking Strategy: Use the process of elimination and note the strategic word “initially.” Note the relationship between the words “at risk for self-harm” in the question and “‘no suicide’ contract” in the correct option. Review initial interventions for the client at risk for suicide if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Mental Health Question 15 1 / 1 pts A client says to the nurse, “I’m worried about my husband. He’s talking about ending it all since his law practice dropped off and his son by his late first wife died of a drug overdose—but he’s too intelligent to hurt himself, isn’t he?” Which response by the nurse is appropriate? “Yes, he’s too intelligent to end it all.” “I’m not sure. I don’t know him that well.” “Most people who talk about ending it all are just looking for attention.” 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) “Your husband is displaying behaviors that indicate a risk for selfharm.” Correct! Rationale: Risk factors for suicide include male gender, professional status (physician, attorney, dentist, military personnel), loss to death, financial problems, and physical illness. Other risk indicators include a suicide plan, depressed mood, and prior attempts at suicide. In stating “Yes, he’s too intelligent to end it all,” the nurse provides false reassurance. In responding “I’m not sure. I don’t know him that well,” the nurse may be accurate, but the answer avoids the client’s concern. The statement “Most people who talk about ending it all are just looking for attention” is inaccurate. Any implication of suicide should be taken seriously. Test-Taking Strategy: Use the process of elimination and focus on the data in the question. Recalling the risk factors associated with suicide will direct you to the correct option. Review risk factors for self harm if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Ques 1 / 1 pts tion 16 A client says to the nurse, “I came in to see you because I’ve been off my medication for 4 years but I feel as though I may be getting depressed again. I’ve been despondent and thinking I should have ended it. That’s why I’m here to get help.” Which response by the nurse would be therapeutic? “Well, you really have had a good long drug-free time, but it sounds as if the doctor needs to reorder your medication at once.” 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) “If you’ve been able to be drug free all this time, you probably don’t need to restart the medicine. You probably just need some therapy to help you manage stress.” “Well, it’s been more than 4 years, so you’ve done really well. Sounds like you’re right about getting depressed again, though. Can you tell me what’s been happening with you lately?” Correct! “Well, it’s similar to when a client is battered; things have to boil over before the police can act, so you need to be suicidal to get admitted to a hospital or hurt yourself before the doctor can restart the medication.” 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: The therapeutic response is the one in which the nurse validates the client’s drug-free time. In addition, in the correct option the nurse validates the client’s selfassessment and supports and offers positive reinforcement. Finally the nurse begins to assess the client completely and attempts to identify precipitants. By stating “Well, you really have had a good long drug-free time, but it sounds as if the doctor needs to reorder your medication at once,” the nurse is premature in determining that the medication needs to be restarted; a thorough assessment must be performed first. In stating “If you’ve been able to be drug free all this time, you probably don’t need to restart the medicine. You probably just need some therapy to help you manage stress,” the nurse jumps to giving advice and offering suggestions without performing a complete assessment. In stating “Well, it’s similar to when a client gets battered; things have to boil over before the police can act, so you need to be suicidal to get admitted to a hospital or hurt yourself before the doctor can restart the medication,” the nurse provides an incorrect statement and sarcastic information. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques and the steps of the nursing process, remembering that assessment is the first step. The only option that involves the process of assessment is the correct option. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Question 17 1 / 1 pts A client who delivered a baby 4 months ago says, “I keep thinking that this boy is some sort of demon. All he does is cry. It’s as if I can’t feed him enough or satisfy him in any way. My daughter never gave me this kind of trouble. I really can’t stand it.” Which statement by the nurse is most important? 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Correct! “Have you been having any thoughts of hurting your baby?” “Do you think that something physically wrong is causing your baby to cry?” “Do you think that your baby cries so frequently because he’s not getting enough nourishment from breastfeeding?” “You say that he doesn’t seem to be satisfied. Do you feel that this is significantly different from when your daughter was a baby?” Rationale: The most important statement is the one in which the nurse assesses the client for her risk of harming the baby. This client may be experiencing postpartum depression, and the rumination over the baby could lead the mother to harm the baby. The statements in the incorrect options change the subject and close off expressions of concern by the client. Test-Taking Strategy: Use knowledge of the subject, potential for harm to others, to assist you with the process of elimination. Noting the words “I really can’t stand it” in the question will direct you to the correct option. Review assessment of the client at risk for harming others if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Communication and Documentation Content Area: Mental Health Question 18 1 / 1 pts A client who is an alcoholic has been admitted to the mental health unit and states to the nurse, “The judge made me come in here. My blood alcohol level was only 0.20% when the cop pulled 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) me over in my car.” Which statement by the nurse is most appropriate? “Did you ask the judge to clarify his decision to make you come here?” “This limit means that you had consumed enough alcohol to put you close to the legal intoxication level. You were lucky because you just missed that level.” “Well, the legal limit is much less than that, so you avoided a drunken driving charge by coming here. Seems to me that the judge treated you pretty leniently by allowing you to take refuge here. Don’t you agree?” “This level means that you consumed several drinks of alcohol and would be experiencing depressed motor function of the brain. You would have been staggering and clumsy, and your judgment would have been impaired, but you seem to feel that the judge was unreasonable for sending you here.” Correct! 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: In most states (although the blood alcohol level, or BAL—designated as the indicator of intoxication—does vary), the legal alcohol limit is 0.08%. The most appropriate response is the one that teaches the client about his BAL and directs him to focus on his action and behaviors. In asking “Did you ask the judge to clarify his decision to make you come here?” the nurse seeks clarification from the client, which closes off the expression of feelings by changing the focus of the discussion. In stating “This reading means that you had consumed enough alcohol to put you close to the legal intoxication level. You were lucky because you just missed that level,” the nurse gives inaccurate information about the BAL. In responding “Well, the legal limit is much less than that, so you avoided a drunken driving charge by coming here. Seems to me that the judge treated you pretty leniently by allowing you to take refuge here. Don’t you agree?” the nurse gives opinions and is judgmental, then asks for agreement in a sarcastic style of communication. Test-Taking Strategy: Use the process of elimination and your knowledge of the subject, BAL. Recalling that in most states the legal alcohol limit is 0.08% will direct you to the correct option. Eliminate options that do not show use of therapeutic communication techniques. Review the BAL and therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Question 19 0 / 1 pts An adolescent client has graduated high school and is preparing to leave home to attend college. The adolescent is distressed about this life change. The nurse plans to implement crisis interventions, knowing that this situation is characteristic of which type of crisis? A situational crisis 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) You Answered An individual crisis Correct Answer A maturational crisis An adventitious crisis Rationale: A maturational crisis involves the normal life transitions that produce changes in individuals and how they perceive themselves, their roles, and their status. A situational crisis occurs when a specific external event disturbs an individual’s psychological equilibrium. An adventitious crisis is an unpredictable tragedy that occurs without warning. An individual may experience crisis; however, there is no formal type of crisis known as “individual crisis.” Test-Taking Strategy: Use the process of elimination and your knowledge of the subject, various types of crises. Focus on the data in the question to direct you to the correct option. Review the description of the types of crises if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Question 20 1 / 1 pts A heroin addict who overdoses on the drug is brought into the emergency department. The client is having seizures, and the nurse notes that his pupils are constricted. Which intervention does the nurse anticipate that the emergency department health care provider will prescribe? Gastric lavage Intravenous fluid 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Correct! Naloxone Ammonium chloride Rationale: An opioid antagonist such as naloxone would be prescribed to treat a heroin overdose to reverse central nervous system depression. Gastric lavage is used for oral overdose of or oral poisoning with certain substances. Intravenous fluid is a general intervention in many situations. Ammonium chloride is used to acidify the urine of a client who overdoses on amphetamines. Test-Taking Strategy: Focus on the subject, an overdose of heroin. Recalling that naloxone is an opioid antagonist will direct you to the correct option. Review this naloxone and the treatment for heroin overdose if you had difficulty with this question. Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Question 21 1 / 1 pts A client in a retirement center rings the night alarm and says to the nurse, “Look at this old man! He keeps breaking into my apartment! You’ve got to get him to stay out of here so I can sleep.” Which statement by the nurse would be most therapeutic? “Why not just throw him out yourself and lock up once and for all?” “Now, you know that you’re always seeing things and people at night who aren’t there.” 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) “This must be very troubling to you, but I can’t see the old man. Perhaps I could stay with you for an hour or so while you try to rest.” Correct! “I’m sure you’re very frightened right now. Do you recall my telling you that this is called sundowner syndrome? Go to sleep and he’ll leave your apartment.” Rationale: The most therapeutic nursing response is the one that expresses empathy and helps orient the client to reality. It also offers self, builds trust, and provides support for the client’s distress. In asking “Why not just throw him out yourself and lock up once and for all?” the nurse reinforces the hallucination and delusional thinking by responding as if the old man is really there. In stating “Now, you know that you’re always seeing things and people at night who aren’t there,” the nurse is patronizing and belittling in responding to the client’s concerns, a nontherapeutic communication. In responding “I’m sure that you’re very frightened right now. Do you recall my telling you that this is called sundowner syndrome? Go to sleep and he’ll leave your apartment,” the nurse is lecturing the client and giving advice, which is not therapeutic. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. The only option that addresses the client’s fears and feelings is the correct option. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Question 22 1 / 1 pts 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) A client with schizophrenia is seen seemingly talking to someone who isn’t there. Which nursing statement would be most therapeutic initially? “Today is my birthday. Would you like to go on an outing with my family?” “You need to wash up and get ready to go to supper in the cafeteria with the other clients now.” “I’ve noticed your eyes darting back and forth, and I wondered whether you might be hearing voices.” Correct! “You were telling me yesterday that your mother died last June of cancer. Can you tell me more about that?” 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: The most therapeutic nursing statement is the one in which the nurse addresses the client’s behavior and asks whether the client is hearing voices. With this statement, the nurse also assesses the client’s behavior. If the client is hearing voices, the nurse prevents reinforcement of the hallucinatory thinking by telling the client that he or she does not hear them. In asking “Today is my birthday. Would you like to go on an outing with my family?” the nurse nontherapeutically changes the focus from the client. In stating “You need to wash up and get ready to go to supper in the cafeteria with the other clients now,” the nurse ignores the client’s obvious psychotic behavior and directs the client to socialize with others. Such an intervention is not usually positive because it floods the client with stimuli that may contribute to an escalation of psychotic behavior. In asking “You were telling me yesterday that your mother died last June of cancer. Can you tell me more about that?” the nurse uses distraction, summarization, and refocusing. Test-Taking Strategy: Note the strategic word “initially” and eliminate the options that are unrelated to the client’s behavior. Also, focus on the data in the question. The correct option is the only one that addresses the client’s behavior. Review care of the client who is hallucinating if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Question 23 1 / 1 pts A nurse brings a meal tray to a client with psychosis who is in his hospital room. The client refuses the meal and says, “I’m not eating any more poisoned food while I’m vacationing here. I’m starting on a fast to stay healthy and alive.” Which nursing intervention would be most appropriate initially? Taking the tray away and canceling all meals until further notice 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Having the client eat with other clients in the community dining room Correct! Eating some of the food from the client s tray to prove that it isn t poisoned Telling the client that the psychiatrist will be called for a prescription for a tube feeding Rationale: Having the client eat with other clients in the community room decreases the amount of time in which the client can stay isolated and engage in suspicious thinking. Of the options provided, this would be the initial intervention. It does not guarantee that the client will eat but does reduce the client’s isolation time. Taking the tray away and canceling all meals until further notice and eating some of the food off the client’s tray to prove that it isn’t poisoned are both incorrect because they support the client’s delusional thinking. Telling the client that the psychiatrist will be called for a prescription for a tube feeding is incorrect because it is a premature action that would lead to a regressive struggle with the client and is also a threat to the client. Test-Taking Strategy: Note the strategic word “initially.” First eliminate the option in which the nurse threatens the client. From the remaining options, eliminate comparable or alike options that support the client’s delusional thinking, a nontherapeutic intervention. Review care of the client with psychosis if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Question 24 1 / 1 pts 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) A nurse caring for a client with schizophrenia is assessing the client’s ability to control distorted thought processes. Which finding indicates a positive outcome? The client is able to identify when hallucinations or delusions are real. The client can describe in detail the frequency and context of the hallucinatory and delusional behavior. The client can describe the hallucinations and delusions in detail and is able to interact with others and share in their delusional systems. The client can identify the recurrence of hallucinations, can refrain from responding to them, and reports a significant decrease in the incidence of hallucinations. Correct! 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: Identifying the reoccurrence of hallucinations, refraining from responding to them, and reporting a significant decrease in the incidence of hallucinations are all positive client outcomes. Other positive outcomes include appropriately interacting with others, demonstrating thinking that is based in reality, and grasping others’ ideas. The other options are incorrect because they are not positive outcomes with regard to the client’s ability to control distorted thought processes and focus on the reality of the distorted thought processes. Test-Taking Strategy: Use the process of elimination. Focus on the subject, the client’s ability to control distorted thought processes. The correct option is the only one that identifies control. Review care of the client who is experiencing distorted thought processes if you had difficulty with this question. Cognitive Ability: Evaluating Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Evaluation Content Area: Mental Health Question 25 1 / 1 pts A client with schizophrenia says, “I feel like I’m rotting away inside and all of my organs are rusting.” Which type of delusion does the nurse identify in the client’s statement? Correct! Somatic Jealousy Persecution Idea of reference 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: Somatic delusions are false beliefs that one’s body is changing in an unusual way, such as rusting or rotting away. The most therapeutic intervention in such a situation is to gain the client’s cooperation in taking the antipsychotic medication prescribed by the psychiatrist. A delusion of jealousy is the false belief that one’s significant other is being unfaithful. A delusion of persecution is the false belief that one is being singled out for harm by others. This usually takes the form of a plot by individuals in power against the person. A client subject to ideas of reference misconstrues trivial events and remarks so that he or she may attach personal significance to them. Test-Taking Strategy: Use the process of elimination and your knowledge of the subject, various types of delusions. Note the data in the question, and remember that the client is describing a physiological manifestation. This will direct you to the correct option. Review the different types of delusions if you had difficulty with this question. Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Assessment Content Area: Mental Health Question 26 1 / 1 pts A client with schizophrenia is attending a support group held by a clinic nurse and says to the nurse and the group, “I’ve been laid off from my job at the factory, and so have 300 other people, so I’ll have to get a new job. For now, there’s unemployment.” Which statement by the nurse would be most therapeutic at this time? “It seems that the stock market is responsible for mass unemployment in our factory-based city.” “I’m sorry to hear that you’ve lost your job. Why not make an appointment to come in and talk with me this week?” 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) “How do people feel about this loss of employment? Does anyone in the group who experienced this have any advice?” “Have other people in the group been feeling the job crunch this week? When changes like this occur, it’s best to increase the number of your appointments with me for a short time.” Correct! Rationale: The nurse is leading a support group for schizophrenic clients, so it is important to address every group member when possible and not single out one member for special attention. The correct option is openended, encourages group sharing of experiences and support, and teaches the members about the need to increase visits whenever schedules change abruptly and create stressful situations. In stating “It seems that the stock market is responsible for mass unemployment in our factory-based city,” the nurse changes the focus from feelings and experiences to intellectualize, a nontherapeutic intervention. In responding “I’m sorry to hear that you’ve lost your job. Why not make an appointment to come in and talk with me this week?” the nurse expresses sympathy rather than empathy and personalizes the invitation for an appointment that may cause jealousy among the other clients in the group. In asking “How do people feel about this loss of employment? Does anyone in the group who experienced this have any advice?” the nurse asks a question of the group that is off focus. Test-Taking Strategy: Focus on the environment of the question, a support group. The only option that addresses all members of the group is the correct option. It is also the umbrella option. Review the functions of support groups if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Question 27 1 / 1 pts A client with schizophrenia arrives for a scheduled appointment with the mental health nurse. The nurse notes that the client’s hygiene is poor and that the client is having difficulty concentrating on what the nurse is saying and responding appropriately. Which nursing intervention would be most appropriate? Saying nothing and contacting the psychiatrist to sign a commitment order Saying, “I notice that you don’t seem to be caring for yourself. Are you taking your medication?” Correct! Giving the client his antipsychotic medication and asking him to return in the morning for a follow-up visit Asking, “Will you voluntarily admit yourself for a couple of days so that you can straighten out your medicine and thinking?” 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: When the nurse’s observations indicate that the client is noncompliant with his medicine, the most appropriate intervention is the one in which the nurse makes observations and assesses noncompliance. Saying nothing and contacting the psychiatrist to sign a commitment order is inappropriate. Commitment proceedings may be necessary if the client is a danger to self or others. Giving the client his antipsychotic medication and asking him to return in the morning for a follow-up visit is inappropriate because the client needs assessment and intervention immediately. Waiting until the next morning does not meet the client’s immediate needs. In asking “Will you voluntarily admit yourself for a couple of days so that you can straighten out your medicine and thinking?” the nurse asks the client to enter the hospital voluntarily. This intervention is premature because further assessment of the client is needed. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that involve a delay in addressing the client’s needs. To select from the remaining options, focus on the data in the question and choose the one that addresses observations made by the nurse. Review care of the client with schizophrenia and observations that indicate medication noncompliance if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Question 28 1 / 1 pts A postpartum client says to the nurse, “Sometimes I hear voices telling me to kill my baby to save her all the heartache I’ve been through.” Which statement by the nurse would be most therapeutic? “The voices will disappear in a few weeks as your hormones stabilize.” 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) “This must be very distressing to you. Can you tell me more about the voices?” “It is so good that you shared your feelings and thoughts with me. I’m going to help you get immediate attention for your voices.” Correct! “You will want to tell the doctor about them when you visit him next week. He is very interested in these voices and will want to help you with them.” Rationale: The client is experiencing serious postpartum psychosis and command hallucinations. They require immediate medical attention and intervention for the protection of both the mother and her baby. In stating “The voices will disappear in a few weeks as your hormones stabilize,” the nurse disregards serious clinical manifestations. In responding, “This must be very distressing to you. Can you tell me more about the voices?” the nurse is trying to obtain additional data, but the client’s statement indicates a psychiatric emergency that requires immediate intervention. In stating, “You will want to tell the doctor about them when you visit him next week. He is very interested in these voices and will want to help you with them,” the nurse delays and refers the client to a psychiatrist 1 week from now, an intervention that may be too late for the mother and baby. Test-Taking Strategy: Focus on the data in the question, noting the words “voices telling me to kill my baby.” The only option that provides immediate attention to this serious statement is the correct option. Review interventions for the client who indicates the possibility of self-harm or harm to others if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Mental Health 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Question 29 1 / 1 pts A client with schizophrenia exhibits confused and unintelligible speech. Which nursing statement would be most therapeutic? “Got it. The ‘blinks’ are ‘taking over’ the ‘bumpers.’” “I can’t understand what you’re saying. You have to talk more clearly!” “This morning you are participating in the tree-decorating ceremony for the unit.” Correct! “I can’t understand you. Are you asking me to stay with you while you eat supper?” 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: The most therapeutic technique for assisting a client whose speech is confused and unintelligible is to emphasize what is happening in the here and now and involve the client in simple reality-based activities. “Got it. The ‘blinks’ are ‘taking over’ the ‘bumpers’” is unintelligible speech on the part of the nurse and reinforces the client's behavior. In stating “I can’t understand what you’re saying. You have to talk more clearly!” the nurse begins with an appropriate response, but demanding that the client speak more clearly is inappropriate. In responding “I can’t understand you. Are you asking me to stay with you while you eat supper?” the nurse is guessing at what the client has said. Test-Taking Strategy: Use knowledge of the subject, communication with a client using unintelligible speech, to assist you with the process of elimination. First eliminate the option that is unintelligible. Next eliminate the option that is demanding that the client speak more clearly. As you choose from the remaining options, remember that a client with schizophrenia who exhibits confusion and unintelligible speech should be involved in simple realitybased activities. Review care of the client with schizophrenia if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Question 30 1 / 1 pts A client with schizophrenia says to the nurse, “I keep getting these thoughts and hearing voices. They worry and consume me so that I can’t always stop myself like my doctor told me to.” Which intervention would the nurse suggest as a distraction technique? “Pretend that you’re on the phone and talk to the voices.” Correct! “Have you tried to count back from 100 or listen to music?” 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) “The next time this happens, try telling the voices to go away.” “Tell the voices that you will only listen to them just before you watch television at 8:30 in the evening.” Rationale: Distracting ways of coping with voices include reading aloud, describing an object in detail, listening to music, and watching television. Having the client try to count back from 100 or listen to music will assist in distraction. In the remaining options, the nurse suggests interacting techniques that reinforce the client’s belief that the voices are real. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that indicate that the voices are real. Review care of the client with schizophrenia who is hallucinating if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Ques 1 / 1 pts tion 31 A nurse is participating in a care planning conference for a client who is being treated for psychosis. Which step would be included during the stable or discharge phase of treatment? Evaluation of neurological status Use of directive communications with the client Administration of acute psychotropic medications Correct! Keeping the client active with hobbies, exercise, and work 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: Desired outcomes for a psychotic client during the stable or discharge phase of treatment include maintenance of a consistent sleeping pattern; avoidance of caffeine and alcohol; maintenance of daily and weekly routines, including enjoyable activities; and a regular medication schedule. Evaluation of neurological status, the use of directive communications, and the administration of acute psychotropic medications with the client are all active-phase interventions. Test-Taking Strategy: Use the process of elimination and focus on the subject, the stable or discharge phase of treatment. First eliminate the option that contains the word “acute.” To select from the remaining options, focus on the subject. Evaluation of neurological status and use of directive communications with the client are part of the acute phase of treatment. Review interventions for the client with psychosis who is preparing for discharge if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Question 32 1 / 1 pts A client with schizophrenia is admitted to the inpatient psychiatric unit. The client is exhibiting clang associations, word salad, and loose associations. Which problem does the nurse recognize that the client is experiencing? Defensive coping Inability to cope effectively Sensory perception alterations Correct! Inability to communicate effectively 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: Clang associations, word salad, and loose associations are language disturbances that indicate a client’s inability to communicate effectively. These manifestations are not associated with coping or sensory alterations. Test-Taking Strategy: Focus on the data in the question. Eliminate the comparable or alike options: Defensive coping is the same as inability to cope effectively. To select from the remaining options, recall that clang associations, word salad, and loose associations are signs of disturbed thought process and impaired verbal communication, which will direct you to the correct option. Review the characteristics of schizophrenia if you had difficulty with this question. Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Question 33 1 / 1 pts A 24-year-old client with schizophrenia says, “I was in college and suddenly I was hearing voices telling me I was no good and that I should jump off the bridge by our college. My parents came and got me when I called them. We thought that I had inadvertently taken drugs at a party or something. My psychiatrist says that if I can improve, I can return to college next semester.” Which guideline does the nurse plan to incorporate into teaching of the client and family about self-care on the client’s return to college? Compliance with the treatment regimen, immediate reporting of any relapse signs, avoidance of alcohol and drugs, and living a balanced lifestyle Correct! 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Telling all friends about the illness so that they support the client s avoidance of alcohol and drugs and help the client maintain a balanced lifestyle Limiting college attendance to commuter status to maintain a supportive family group and avoiding drugs, alcohol, and the strain of socialization Compliance with treatment, immediate reporting of any relapse signs, avoidance of alcohol and drugs, and socialization with one supportive friend Rationale: Self-care guidelines for the client include compliance with the treatment regimen, immediate reporting of any relapse signs, avoidance of alcohol and drugs, and living a balanced lifestyle. Telling all friends about the illness so that they can support the client’s avoidance of alcohol and drugs and help the client maintain a balanced lifestyle is incorrect. Although the closest supportive friends need to know and understand the illness, not everybody does. Limiting college attendance to commuter status to maintain a supportive family group and avoiding drugs, alcohol, and the strain of socialization is incorrect. Not allowing the client to be independent and follow a normal growth and development pattern would retard the client’s growth. Socializing with one supportive friend is incorrect because it is best to bring as many supportive persons to the client as possible. Test-Taking Strategy: Use the process of elimination and focus on the data in the question and the subject, selfcare. Eliminate the options that contain the words “one,” “all,” and “limiting.” Also note that the correct option is the umbrella option. Review care of the client with schizophre