Mental Health HESI

Mental Health HESI Related

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A female client on a psychiatric unit is sweating profusely while vigorously doing push-ups and then running the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbance, the client shouts, "I am the boss here. I do what I want." Which nursing problem best supports these observations?

  • A. Deficient diversional activity related to excess energy level.
  • B. Disturbed personal identity related to grandiosity.
  • C. Risk for activity intolerance related to hyperactivity.
  • D. Risk for other-directed violence related to disruptive behaviors.
Correct Answer: D

Rationale: The client's behavior of engaging in disruptive and aggressive actions, as well as claiming authority over others in the setting, indicates a risk for other-directed violence. This behavior poses a potential threat to the safety of others in the environment. Choice A is incorrect as the client's behavior is not solely indicative of a lack of diversional activities but rather a more serious issue. Choice B is incorrect as the behavior described does not primarily reflect disturbances in personal identity but rather displays of power and aggression. Choice C is incorrect as the client's actions do not suggest an intolerance to activity but rather an excessive and potentially harmful level of hyperactivity.

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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.

What assessment questions should the nurse ask when attempting to determine a teenager's mental health resilience? Select all that apply.

  • A. How did you cope when your father deployed with the Army for a year in Iraq?
  • B. Who did you go to for advice while your father was away for a year in Iraq?
  • C. How do you feel about talking to a mental health counselor?
  • D. Where do you see yourself in 10 years?
Correct Answer: C

Rationale: The question 'How do you feel about talking to a mental health counselor?' is the most appropriate to assess the teenager's mental health resilience as it directly addresses their willingness to seek help and cope effectively. Choices A and B focus on coping mechanisms during a specific event, which may not reflect the teenager's overall resilience. Choice D is more related to future aspirations rather than assessing current mental health resilience.

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 nurse is developing unit policies that will include nursing guidelines for maintaining a therapeutic milieu. Which interventions should be included when providing a therapeutic milieu in an inpatient setting?

  • A. Opportunities to contribute to one's treatment plan.
  • B. One-on-one dialogue sessions with the therapist.
  • C. Regularly scheduled unit activities for peer interaction.
  • D. Home visits to reintegrate into the family.
Correct Answer: C

Rationale: The nurse is responsible for maintaining a therapeutic milieu in an inpatient setting, which involves creating a secure and structured environment that promotes client safety and offers opportunities for clients to learn healthy coping skills. Regularly scheduled unit activities for peer interaction help foster socialization, support, and a sense of community among clients. Choices A and B are valuable interventions in mental health care but do not directly relate to creating a therapeutic milieu in an inpatient setting. Choice D, home visits, would typically occur post-discharge and focus on community reintegration, rather than maintaining a therapeutic milieu within the inpatient setting.

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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