Psychiatric/Mental Health Assignment Exam Hesi Practice Part 2
1. The nurse should include which interventions in the plan
of care for a severely depressed client with neurovegetative
symptoms? (Select all that apply.)
Permit rest periods as
needed. Speaking slowly
and simply.
Place the client on suicide
precautions. Observe and encourage
food and fluid intake.
Encourage vigorous exercise and long walks on the unit.:
ANS: Permit rest periods as needed.
Speaking slowly and simply.
Place the client on suicide precautions.
Observe and encourage food and fluid
intake.
Neurovegetative symptoms that accompany the mood disorder of
depression in- clude physiological disruptions, such as anorexia,
constipation, sleep disturbance, and psychomotor retardation. The
client's plan of care should include measures that promote the client's
comfort and well-being, such as rest, nutrition, suicide precautions,
and simple communications. Vigorous exercise and long walks are not
indicated for clients in a neurovegetative state.
2. The nurse is planning the care for an adult client with
acute depression. Which intervention should the nurse
implement to help the client deal with depression?
Ensure that the client's day is filled with group activities.
Assist the client in exploring feelings of shame,
anger, and guilt. Allow the client to initiate and
determine activities of daily living.
Encourage the client to explore the rationale for depression.:
ANS: Assist the client in exploring feelings of shame, anger, and guilt.
Depression is associated with feelings of shame, anger, and guilt.
Exploring such feelings with the client is an important nursing
intervention for a client who is acutely depressed. The other
,interventions are not indicated.
3. A client who is being treated with lithium carbonate for
bipolar disorder develops diarrhea, vomiting, and drowsiness.
What action should the nurse take?
Notify the healthcare provider immediately and prepare for
administration of
, an antidote.
Notify the healthcare provider of the symptoms prior to the
next administra- tion of the drug.
Record the symptoms as normal side effects and continue
administration of the prescribed dosage.
Hold the medication and refuse to administer additional
amounts of the drug.: ANS: Notify the healthcare provider of the
symptoms prior to the next administration of the drug.
Early side effects of lithium carbonate that occur with a serum lithium
levels below
2.0 mEq/L generally follow a progressive pattern beginning with
diarrhea, vomiting, drowsiness, and muscular weakness. The nurse
should notify the healthcare provider before giving the next dose,
which can contribute to higher serum drug levels that may cause
ataxia, tinnitus, blurred vision, and large dilute urine output. The other
actions are not indicated.
4. An older female client with Alzheimer's disease is
wandering the busy halls of the extended care facility and
asks the nurse, "Where should I stand for the parade?" Which
response should the nurse provide?
Anywhere you want to stand as long as you do not get hurt by
those in the parade.
You are confused because of all the activity in the hall. There is
no parade. Let's go back to the activity room and see what is
going on in there.
Remember I told you that this is a nursing home and I am your
nurse.: ANS: Let's go back to the activity room and see what is going
on in there.
It is common for those with Alzheimer's disease (AD) to use the wrong
words. Redirecting the client, using an accepting non-judgmental
dialogue, to a safer place and familiar activities is most helpful
because clients with AD experience short-term memory loss. The other
responses dismiss the client's attempt to find order, do not help her
relate to the surroundings, and are frustrating which increase anxiety
level.
5. The nurse is leading a "current events group" with client
1. The nurse should include which interventions in the plan
of care for a severely depressed client with neurovegetative
symptoms? (Select all that apply.)
Permit rest periods as
needed. Speaking slowly
and simply.
Place the client on suicide
precautions. Observe and encourage
food and fluid intake.
Encourage vigorous exercise and long walks on the unit.:
ANS: Permit rest periods as needed.
Speaking slowly and simply.
Place the client on suicide precautions.
Observe and encourage food and fluid
intake.
Neurovegetative symptoms that accompany the mood disorder of
depression in- clude physiological disruptions, such as anorexia,
constipation, sleep disturbance, and psychomotor retardation. The
client's plan of care should include measures that promote the client's
comfort and well-being, such as rest, nutrition, suicide precautions,
and simple communications. Vigorous exercise and long walks are not
indicated for clients in a neurovegetative state.
2. The nurse is planning the care for an adult client with
acute depression. Which intervention should the nurse
implement to help the client deal with depression?
Ensure that the client's day is filled with group activities.
Assist the client in exploring feelings of shame,
anger, and guilt. Allow the client to initiate and
determine activities of daily living.
Encourage the client to explore the rationale for depression.:
ANS: Assist the client in exploring feelings of shame, anger, and guilt.
Depression is associated with feelings of shame, anger, and guilt.
Exploring such feelings with the client is an important nursing
intervention for a client who is acutely depressed. The other
,interventions are not indicated.
3. A client who is being treated with lithium carbonate for
bipolar disorder develops diarrhea, vomiting, and drowsiness.
What action should the nurse take?
Notify the healthcare provider immediately and prepare for
administration of
, an antidote.
Notify the healthcare provider of the symptoms prior to the
next administra- tion of the drug.
Record the symptoms as normal side effects and continue
administration of the prescribed dosage.
Hold the medication and refuse to administer additional
amounts of the drug.: ANS: Notify the healthcare provider of the
symptoms prior to the next administration of the drug.
Early side effects of lithium carbonate that occur with a serum lithium
levels below
2.0 mEq/L generally follow a progressive pattern beginning with
diarrhea, vomiting, drowsiness, and muscular weakness. The nurse
should notify the healthcare provider before giving the next dose,
which can contribute to higher serum drug levels that may cause
ataxia, tinnitus, blurred vision, and large dilute urine output. The other
actions are not indicated.
4. An older female client with Alzheimer's disease is
wandering the busy halls of the extended care facility and
asks the nurse, "Where should I stand for the parade?" Which
response should the nurse provide?
Anywhere you want to stand as long as you do not get hurt by
those in the parade.
You are confused because of all the activity in the hall. There is
no parade. Let's go back to the activity room and see what is
going on in there.
Remember I told you that this is a nursing home and I am your
nurse.: ANS: Let's go back to the activity room and see what is going
on in there.
It is common for those with Alzheimer's disease (AD) to use the wrong
words. Redirecting the client, using an accepting non-judgmental
dialogue, to a safer place and familiar activities is most helpful
because clients with AD experience short-term memory loss. The other
responses dismiss the client's attempt to find order, do not help her
relate to the surroundings, and are frustrating which increase anxiety
level.
5. The nurse is leading a "current events group" with client
