Mental Health Practice HESI 2021/2022

A male client with schizophrenia who is taking fluphenazine decanoate (Prolixin decanoate) is being discharged in the morning. A repeat dose of medication is scheduled for 20 days after discharge. The client tells the nurse that he is going on vacation in the Bahamas and will return in 18 days. Which statement by the client indicates a need for health teaching? A) When I return from my tropical island vacation, I will go to the clinic to get my Prolixin injection. B) While I am on vacation and when I return, I will not eat or drink anything that contains alcohol. C) I will notify the healthcare provider if I have a sore throat or flu-like symptoms. D) I will continue to take my benztropine mesylate (Cogentin) every day. answer- Photosensitivity is a side effect of Prolixin and a vacation in the Bahamas (with its tropical island climate) increases the client's chance of experiencing this side effect. He should be instructed to avoid direct sun (A) and wear sunscreen. (B, C, and D) indicate accurate knowledge. Alcohol acts synergistically with Prolixin (B). (C) lists signs of agranulocytosis, which is also a side effect of Prolixin. In order to avoid extrapyramidal symptoms (EPS), anticholinergic drugs, such as Cogentin, are often prescribed prophylactically with Prolixin. Correct Answer(s): A 2. A male client is admitted to the mental health unit because he was feeling depressed about the loss of his wife and job. The client has a history of alcohol dependency and admits that he was drinking alcohol 12 hours ago. Vital signs are: temperature, 100° F, pulse 100, and BP 142/100. The nurse plans to give the client lorazepam (Ativan) based on which priority nursing diagnosis? A) Risk for injury related to suicidal ideation. B) Risk for injury related to alcohol detoxification. C) Knowledge deficit related to ineffective coping. D) Health seeking behaviors related to personal crisis. answer- The most important nursing diagnosis is related to alcohol detoxification (B) because the client has elevated vital signs, a sign of alcohol detoxification. Maintaining client safety related to (A) should be addressed after giving the client Ativan for elevated vital signs secondary to alcohol withdrawal. (C and D) can be addressed when immediate needs for safety are met. Correct Answer(s): B 3. The charge nurse is collaborating with the nursing staff about the plan of care for a client who is very depressed. What is the most important intervention to implement during the first 48 hours after the client's admission to the unit? A) Monitor appetite and observe intake at meals. B) Maintain safety in the client's milieu. C) Provide ongoing, supportive contact. D) Encourage participation in activities. answer- The most important reason for closely observing a depressed client immediately after admission is to maintain safety (B), since suicide is a risk with depression. (A, C, and D) are all important interventions, but safety is the priority. Correct Answer(s): B 4. A 38-year-old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her, she refuses to eat and tells the nurse, "I know you are trying to poison me with that food." Which response is most appropriate for the nurse to make? A) I'll leave your tray here. I am available if you need anything else. B) You're not being poisoned. Why do you think someone is trying to poison you? C) No one on this unit has ever died from poisoning. You're safe here. D) I will talk to your healthcare provider about the possibility of changing your diet. answer- (A) is the best choice cited. The nurse does not argue with the client nor demand that she eat, but offers support by agreeing to "be there if needed", e.g., to warm the food. (B and C) are arguing with the client's delusions, and (B) asks "why" which is usually not a good question for a psychotic client. (D) has nothing to do with the actual problem; i.e., the problem is not the diet (she thinks any food given to her is poisoned.) Correct Answer(s): A 5. A client who is being treated with lithium carbonate for bipolar disorder develops diarrhea, vomiting, and drowsiness. What action should the nurse take? A) Notify the healthcare provider immediately and prepare for administration of an antidote. B) Notify the healthcare provider of the symptoms prior to the next administration of the drug. C) Record the symptoms as normal side effects and continue administration of the prescribed dosage. D) Hold the medication and refuse to administer additional amounts of the drug. answer- Early side effects of lithium carbonate (occurring with serum lithium levels below 2.0 mEq per liter) generally follow a progressive pattern beginning with diarrhea, vomiting, drowsiness, and muscular weakness. At higher levels, ataxia, tinnitus, blurred vision, and large dilute urine output may occur. (B) is the best choice. Although these are expected symptoms, the healthcare provider should be notified prior to the next administration of the drug. (A, C, and D) would not reflect good nursing judgment. Correct Answer(s): B 6. The parents of a 14-year-old boy bring their son to the hospital. He is lethargic, but responsive. The mother states, "I think he took some of my pain pills." During initial assessment of the teenager, what information is most important for the nurse to obtain from the parents? A) If he has seemed depressed recently. B) If a drug overdose has ever occurred before. C) If he might have taken any other drugs. D) If he has a desire to quit taking drugs. answer- Knowledge of all substances taken (C) will guide further treatment, such as administration of antagonists, so obtaining this information has the highest priority. (A and B) are also valuable in planning treatment. (D) is not appropriate during the acute management of a drug overdose. Correct Answer(s): C 7. The wife of a male client recently diagnosed with schizophrenia asks the nurse, "What exactly is schizophrenia? Is my husband all right?" Which response is best for the nurse to provide to this family member? A) It sounds like you're worried about your husband. Let's sit down and talk. B) It is a chemical imbalance in the brain that causes disorganized thinking. C) Your husband will be just fine if he takes his medications regularly. D) I think you should talk to your husband's psychologist about this question. answer- The nurse should answer the client's question with factual information and explain that schizophrenia is a chemical imbalance in the brain (B). (A) is a therapeutic response but does not answer the question, and may be an appropriate response after the nurse answers the question asked. Although (C) is likely true to some degree, it is also true that some clients continue to have disorganized thinking even with antipsychotic medications. Referring the spouse to the psychologist (D) is avoiding the issue; the nurse can and should answer the question. Correct Answer(s): B 8. The community health nurse talks to a male client who has bipolar disorder. The client explains that he sleeps 4 to 5 hours a night and is working with his partner to start two new businesses and build an empire. The client stopped taking his medications several days ago. What nursing problem has the highest priority? A) Excessive work activity. B) Decreased need for sleep. C) Medication management. D) Inflated self-esteem. answer- The most important nursing problem is medication management (C) because compliance with the medication regimen will help prevent hospitalization. The client is also exhibiting signs of (A, B, and C); however, these problems do not have the priority of medication management. Correct Answer(s): C 9. At a support meeting of parents of a teenager with polysubstance dependency, a parent states, "Each time my son tries to quit taking drugs, he gets so depressed that I'm afraid he will commit suicide." The nurse's response should be based on which information? A) Addiction is a chronic, incurable disease. B) Tolerance to the effects of drugs causes feelings of depression. C) Feelings of depression frequently lead to drug abuse and addiction. D) Careful monitoring should be provided during withdrawal from the drugs. answer- The priority is to teach the parents that their son will need monitoring and support during withdrawal (D) to ensure that he does not attempt suicide. Although (A and C) are true, they are not as relevant to the parent's expressed concern. There is no information to support (B). Correct Answer(s): D 10. The nurse observes a female client with schizophrenia watching the news on TV. She begins to laugh softly and says, "Yes, my love, I'll do it." When the nurse questions the client about her comment she states, "The news commentator is my lover and he speaks to me each evening. Only I can understand what he says." What is the best response for the nurse to make? A) What do you believe the news commentator said to you? B) Let's watch news on a different television channel. C) Does the news commentator have plans to harm you or others? D) The news commentator is not talking to you. answer- It is imperative that the nurse determine what the client believes she heard (A). The idea of reference may be to hurt herself or someone else, and the main function of a psychiatric nurse is to maintain safety. (B) is acceptable, but it is best to determine the client's beliefs. (C) is validating the idea of reference, while (D) is challenging the client. Correct Answer(s): A 11. At the first meeting of a group of older adults at a daycare center for the elderly, the nurse asks one of the members what kinds of things she would like to do with the group. The older woman shrugs her shoulders and says, "You tell me, you're the leader." What is the best response for the nurse to make? A) Yes, I am the leader today. Would you like to be the leader tomorrow? B) Yes, I will be leading this group. What would you like to accomplish during this time? C) Yes, I have been assigned to be the leader of this group. I will be here for the next six weeks. D) Yes, I am the leader. You seem angry about not being the leader yourself. answer- Anxiety over participation in a group and testing of the leader characteristically occur in the initial phase of group dynamics. (B) provides information and focuses the group back to defining its function. (A) is manipulative bargaining. Although (C) provides information, it does not focus the group on its purpose or task. (D) is interpreting the client's feelings and is almost challenging. Correct Answer(s): B 12. The nurse is planning discharge for a male client with schizophrenia. The client insists that he is returning to his apartment, although the healthcare provider informed him that he will be moving to a boarding home. What is the most important nursing diagnosis for discharge planning? A) Ineffective denial related to situational anxiety. B) Ineffective coping related to inadequate support. C) Social isolation related to difficult interactions. D) Self-care deficit related to cognitive impairment. answer- The best nursing diagnosis is (A) because the client is unable to acknowledge the move to a boarding home. (B, C, and D) are potential nursing diagnoses, but denial is most important because it is a defense mechanism that keeps the client from dealing with his feelings about living arrangements. Correct Answer(s): A 13. Which diet selection by a client who is depressed and taking the MAO inhibitor tranylcypromine sulfate (Parnate) indicates to the nurse that the client understands the dietary restrictions imposed by this medication regimen? A) Hamburger, French fries, and chocolate milkshake. B) Liver and onions, broccoli, and decaffeinated coffee. C) Pepperoni and cheese pizza, tossed salad, and a soft drink. D) Roast beef, baked potato with butter, and iced tea. answer- Only (D) contains no tyramine. Tyramine in foods interacts with MAOI in the body causing a hypertensive crisis which is life-threatening, and Parnate is classified as an MAOI antidepressant. Some items in (A, B, and C) contain tyramine and would not be permitted for a client taking Parnate. Correct Answer(s): D 14. An elderly female client with advanced dementia is admitted to the hospital with a fractured hip. The client repeatedly tells the staff, "Take me home. I want my Mommy." Which response is best for the nurse to provide? A) Orient the client to the time, place, and person. B) Tell the client that the nurse is there and will help her. C) Remind the client that her mother is no longer living. D) Explain the seriousness of her injury and need for hospitalization. answer- Those with dementia often refer to home or parents when seeking security and comfort. The nurse should use the techniques of "offering self" and "talking to the feelings" to provide