Quizlet HESI Mental Health

Quizlet HESI Mental Health Related

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A female client, who is wearing dirty clothes and has a foul body odor, comes to the clinic reporting feeling scared because she is being stalked. What action is most important for the nurse to take?

  • A. Assure the client that the healthcare provider will see her today.
  • B. Recommend that the client talk with a social worker.
  • C. Ask the client to describe why she is being stalked.
  • D. Offer the client a safe place to relax before interviewing her.
Correct Answer: D

Rationale: The most important action for the nurse to take in this scenario is to offer the client a safe place to relax before interviewing her. The client's disheveled appearance and foul body odor suggest she may be in distress or facing challenging circumstances. By providing her with a safe and comfortable environment to relax, the nurse can help alleviate some of her distress and establish trust. This approach is crucial as the client is already feeling scared due to being stalked, indicating underlying mental health concerns. Assuring the client of a healthcare provider visit (choice A) may not address her immediate need for safety and comfort. Recommending she talk with a social worker (choice B) may be beneficial later but does not address the immediate need for a safe space. Asking the client to describe why she is being stalked (choice C) is not appropriate as the priority is ensuring her safety and comfort first.

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A client is agitated and physically aggressive. What action should the RN take first?

  • A. Calmly inform the client that they will be placed in seclusion if they do not calm down.
  • B. Discuss with the client the reasons for their agitation and aggression.
  • C. Tell the client that physical aggression is not acceptable and must stop.
  • D. Seek assistance from other staff members and follow the facility's protocol.
Correct Answer: D

Rationale: In a situation where a client is agitated and physically aggressive, the priority for the RN is to ensure the safety of the client and others. Seeking assistance from other staff members is crucial as it allows for a prompt response to manage the situation effectively and according to the facility's protocol. Choices A, B, and C do not address the immediate need for safety or involve the collaboration of other staff members, which is essential in handling aggressive behaviors in a healthcare setting.

The RN documents the mental status of a female client who has been hospitalized for several days by court order. The client states, "I don't need to be here," and tells the RN that she believes that the TV talks to her. The RN should document these assessment statements in which section of the mental status exam?

  • A. Insight and judgment.
  • B. Mood and affect.
  • C. Remote memory.
  • D. Level of concentration.
Correct Answer: A

Rationale: The client's statement of not needing to be hospitalized and her belief that the TV talks to her indicate impaired insight and judgment. Insight and judgment evaluate the client's awareness of their condition and ability to make sound decisions. Mood and affect assess emotional state, remote memory evaluates recall of past events, and level of concentration assesses attention and focus, none of which directly address the client's lack of insight and judgment in this scenario.

A mental health worker is caring for a client with escalating aggressive behavior. Which action by the mental health worker warrants immediate intervention by the RN?

  • A. Is attempting the physically restrain the patient.
  • B. Remains at a distance of 4 feet from the client.
  • C. Tells the client to go to the quiet area of the unit.
  • D. Is using a loud voice to talk to the client.
Correct Answer: A

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

A client with major depressive disorder is prescribed lithium carbonate. Which finding should the RN report to the healthcare provider?

  • A. Serum lithium level of 0.8 mEq/L
  • B. Blood urea nitrogen (BUN) level of 16 mg/dL
  • C. Serum sodium level of 138 mEq/L
  • D. Urine output of 800 mL in 24 hours
Correct Answer: B

Rationale: The correct answer is B. Elevated BUN levels may indicate renal impairment, which is crucial to report for clients on lithium due to its potential kidney effects. Option A, a serum lithium level of 0.8 mEq/L, is within the therapeutic range for lithium and does not require immediate reporting. Option C, a serum sodium level of 138 mEq/L, is within the normal range and not directly related to lithium therapy. Option D, urine output of 800 mL in 24 hours, may indicate a need for further assessment but is not the most critical finding to report compared to potential renal impairment indicated by an elevated BUN level.

A female client reports feeling hopeless and is unable to stop crying. She explains that she is worried about losing her job. Since the client's husband recently lost his job, she feels her employment is essential to the family's survival. To evaluate the effectiveness of cognitive-behavioral techniques, which client outcomes should the nurse include in the plan of care?

  • A. Relates insights into problematic relationships
  • B. Demonstrates a healthy relationship with her husband
  • C. Describes how the family can resolve problems
  • D. Changes thought patterns related to problem-solving
Correct Answer: D

Rationale: The correct answer is D. Cognitive-behavioral therapy focuses on changing thought patterns by guiding the client to engage in problem-solving strategies to address the current situation. This approach helps individuals modify negative thinking patterns and develop more adaptive ways to cope with challenges. Choices A, B, and C are incorrect because while they may be important aspects to consider in therapy, the primary focus in cognitive-behavioral therapy is on identifying and changing negative thought patterns rather than exploring relationships or family problem-solving skills.

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