Mental Health HESI

Mental Health HESI Related

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A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The RN also determines that the client is homeless and is exhibiting suspiciousness. The client's plan of care should include what priority problem?

  • A. Acute confusion.
  • B. Ineffective community coping.
  • C. Disturbed sensory perception.
  • D. Self-care deficit.
Correct Answer: A

Rationale: Acute confusion is the priority problem because it directly impacts the client's safety and functioning. In this scenario, the client is disoriented, disorganized, and confused, which can pose immediate risks to her well-being. Ineffective community coping, disturbed sensory perception, and self-care deficit are not as urgent in this situation. Ineffective community coping focuses on the client's ability to manage stress related to the community, disturbed sensory perception pertains to alterations in sensory input, and self-care deficit involves the inability to perform activities of daily living independently. While these issues may also need addressing, acute confusion takes precedence due to the immediate safety concerns it presents.

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A client is being educated by a healthcare professional about initiating a prescribed abstinence therapy using Disulfiram (Antabuse). What information should the client acknowledge understanding?

  • A. Admit to others that they are a substance abuser.
  • B. Remain alcohol-free for 12 hours before taking the first dose.
  • C. Attend monthly Alcoholics Anonymous meetings.
  • D. Completely abstain from heroin or cocaine use.
Correct Answer: B

Rationale: B: Before starting Disulfiram therapy, it is crucial for clients to be alcohol-free for a minimum of 12 hours to prevent adverse reactions. A: Admitting substance abuse is important, but it is not directly linked to the initiation of Disulfiram therapy. C: Attending Alcoholics Anonymous meetings is beneficial for support but not a specific requirement for starting Disulfiram. D: The focus of Disulfiram therapy is on alcohol abstinence, so abstaining from heroin or cocaine is not directly related to this medication.

The nurse accepts a transfer to the mental health unit and understands that the client is distractible and is exhibiting a decreased ability to concentrate. The nurse has only 15 minutes to talk with the client. To develop a treatment plan for this client, which assessment is most important for the nurse to obtain?

  • A. Motivation for treatment
  • B. History of substance use
  • C. Medication compliance
  • D. Mental status examination
Correct Answer: D

Rationale: A mental status examination is the most important assessment for the nurse to obtain in this scenario. It provides a comprehensive view of the client's current cognitive functioning, including their level of alertness, orientation, memory, attention, and thought process. Understanding the client's mental status is crucial for developing an appropriate treatment plan. The other options, such as motivation for treatment, history of substance use, and medication compliance, are important aspects to consider but may not directly address the client's current cognitive state and immediate treatment needs as effectively as a mental status examination.

A client with anorexia nervosa has a body mass index (BMI) of 16.5 and has been diagnosed with bradycardia. Which of the following findings should the RN be most concerned about?

  • A. Body temperature of 96.8°F.
  • B. Heart rate of 52 BPM.
  • C. Serum potassium level of 4.1 mEq/L.
  • D. Electrocardiogram (ECG) changes.
Correct Answer: D

Rationale: In a client with anorexia nervosa and bradycardia, monitoring for ECG changes is crucial as these changes may indicate potentially life-threatening cardiac complications. While other findings like low body temperature, bradycardia, and serum potassium levels are concerning, ECG changes specifically reflect the impact of bradycardia on the heart's electrical activity and should be the priority for the nurse to assess and address.

A client is being treated for generalized anxiety disorder (GAD) and is prescribed an SSRI. Which side effect should the nurse educate the client about?

  • A. Weight loss
  • B. Increased appetite
  • C. Insomnia
  • D. Dry mouth
Correct Answer: C

Rationale: The correct answer is C: Insomnia. Insomnia is a common side effect of SSRIs, including those used to treat generalized anxiety disorder (GAD). Educating the client about potential side effects like insomnia is crucial for managing expectations and promoting treatment adherence. Weight loss (choice A) is less common with SSRIs and might not be a primary concern for a client with GAD. Increased appetite (choice B) is also less likely with SSRIs. Dry mouth (choice D) is a side effect more commonly associated with other classes of medications, such as anticholinergics, rather than SSRIs.

The RN is leading a group on the inpatient psychiatric unit. Which approach should the RN use during the working phase of group development?

  • A. Establishing a rapport with group members.
  • B. Clarifying the nurse's role and clients' responsibilities.
  • C. Discussing ways to use new coping skills learned.
  • D. Helping clients identify areas of problems in their lives.
Correct Answer: C

Rationale: During the working phase of group development, the focus should be on discussing and applying new coping skills to promote progress. This helps group members to practice and implement the skills they have learned, leading to positive outcomes. Choices A, B, and D are not ideal during the working phase. While establishing rapport is important, it is more relevant during the initial orientation phase. Clarifying roles and responsibilities is important at the beginning of group formation, and helping clients identify areas of problem in their lives is often part of the exploration phase, not the working phase.

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