Mental Health Hesi 2 Questions and Correct Answers
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the client in the chair?
Ans: A male adult comes to the mental health clinic and walks back and
forth in front of the office door, but does not enter the office. He then
walks around a chair that is in the hallway several times before sitting
down in the chair. What action should the nurse take first observe
plan a list of activities to be carried out daily.
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Ans: A female client engages in repeated checks of door and window
locks. Behavior that prevents her from arriving on time and interferes
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with her ability to function e²ectively. What action should the nurse take
Do you hear voices.
Ans: A male client with schizophrenia is admitted to the mental health
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unit after abruptly stopping his prescription for ziprasidone (Geodon)
one month ago. Which question is most important for the nurse to ask
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the client
Ask client about alcohol quantity, frequency, and time of last drink
Ans: A female client with a history of drinking who was admitted 8
hours ago after receiving treatment for minor abrasions occurred from a
fall at home.
The nurse determines the client's blood alcohol level (BAL) was not
analyzed on administration action should the nurse take
Risk for other related violence related to disruptive
Ans: A female client on a psychiatric unit is sweating profusely while
she vigorously does push-ups and then runs the length of the corridor
several times before crashing into the furniture in the sitting room.
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Picking herself up, she begins to toss chairs aside, looking for a red one
to sit in. When another client objects to the disturbances, the client
shouts," I am the boss here. I do what I want." Which nursing problem
best supports these observations
not attempt to commit suicide
Ans: What is the most important goal for a client diagnosed with major
depression who has been receiving an antidepressant medication for two
weeks
pancreatitis
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Ans: Alcohol-Pancreatitis health assessment of history of alcohol
dependency WHAT ELSE WOULD BE A CONCERN
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Abuse-BAL-
Ans: Anorexia Nervosa-syncope Syncope is a clinical feature
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1. ask the client about alcohol quantity, frequency, and time of the last
drink.
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Ans: 1. Anorexia Nervosa-syncope Syncope is a clinical feature Abuse-
BAL-
Admission A female client with a history of drinking who was admitted 8
hours ago after receiving treatment for minor abrasions occurred from a
fall at home. The nurse determines the client's blood alcohol level (BAL)
was not analyzed on administration action should the nurse take Blood
alcohol level-
1. 1. establish a code with family and friends to signify violence, 2. plan
an escape route to use if the abuser blocks main exit,
3.have a bag ready that has extra clothes for self and children