LATEST UPDATED HESI: Psychiatric-Mental EXAM HEALTH NURSING

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. His temperature is 100.0 F, pulse is 100, and blood pressure is 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 (B). The patient is showing elevated vital signs with an increased temperature, pulse, and blood pressure. The diagnosis for drinking and having these elevations is alcohol detoxification. The other choices are related to his mental health and coping skills which are very important but the detoxification needs to be taken care of first and that is what the Ativan is used for. After the patient's temperature, pulse, and blood pressure decrease then A can happen next then C and D. But the patient must be okay physically to be taken care of mentally I hope this helps and you have a nice day! 2 A nurse working in the emergency room of a children's hospital admits a child whose injuries could have resulted from abuse. Which statement most accurately describes the nurse's responsibility in cases of suspected child abuse? a. Obtain objective data such as x-rays before reporting suspicions. b. Confirm suspicions of abuse with the physician. c. Report any case of suspected child abuse. d.Document injuries to confirm suspected abuse. ANSWER C .The statement that most accurately describes the nurse's responsibility in cases of suspected child abuse is: report any suspected cases of child abuse to the charge nurse. The nurse should inform the charge nurse as health professionals are required by law to report all suspected cases of child abuse to the proper authorities, so that they can work to improve the situation and prevent further harm. 3. A child is brought to the emergency room with a broken arm. Because of other injuries, the nurse suspects the child may be a victim of abuse. When the nurse tries to give the child an injection, the child's mother becomes very loud and shouts, "I won't leave my son! Don't you touch him! You'll hurt my child!" What is the best interpretation of the mother's statements? a. She is regressing to an earlier behavior pattern. b. She is sublimating her anger. c. She is projecting her feelings onto the nurse. d.She is suppressing her fear. ANSWER C.the best interpretation of the mother's statements is that she is projecting her feeling onto the nurse. 4. A client, who is on a 30-day commitment to a drug rehabilitation unit, asks the nurse if he can go for a walk on the grounds of the treatment center. When he is told that his privileges do not include walking on the grounds, the client becomes verbally abusive. Which approach should the nurse take? a. Ask the staff to escort the client to his room. b. Have the client ask his physician to change his privileges. c. Remind the client of the importance of following the rules. d. Disregard the client's inappropriate verbal outburst. C.It is important for clients in drug rehabilitation to follow the rules of the unit in order to maintain a safe and effective treatment environment. When clients become verbally abusive, it can be disruptive to the treatment process and cause conflict among other clients. In this situation, the nurse should remind the client of the importance of following the rules. This will help to maintain a respectful and orderly treatment environment. The nurse should also explain to the client that the rules are in place for his safety and well-being. Drug rehabilitation can be a difficult and challenging process, but following the rules can help to ensure that the client is getting the most out of his treatment. Finally, the nurse should remind the client that the staff is only trying to help him, and that they are not his enemy. The staff wants to see the client succeed in his recovery, and they are only doing their job by enforcing the rules. 5.A client who is known to abuse drugs is admitted to the psychiatric unit. Which medication should the nurse anticipate administering to a client who is exhibiting benzodiazepine withdrawal symptoms? a. Perphenazine (Trilafon). b. Diphenylhydramine (Benadryl). c. Chlordiazepoxide (Librium). d. Isocarboxazid (Marplan). ANSWER (C).Chlordiazepoxide (Librium). 6. A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care? a. Client will not demonstrate cross addiction. b. Co-dependent behaviors will be decreased. c. Excessive CNS stimulation will be reduced. d. Client's level of consciousness will increase. ANSWER (C) 7.A 45-year-old female client is admitted to the psychiatric unit for evaluation. Her husband states that she has been reluctant to leave home for the last six months. The client has not gone to work for a month and has been terminated from her job. She has not left the house since that time. This client is displaying symptoms of which disorder? a. Claustrophobia. b. Acrophobia c. Agoraphobia. d. Necrophobia ANSWER (A) 8.A 19-year-old female client with a diagnosis of anorexia nervosa wants to help serve dinner trays to other clients on a psychiatric unit.