Mental Health HESI Quizlet

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An elderly client diagnosed with delirium is being treated with antipsychotic medication. Which side effect should the nurse monitor for in this client?

  • A. Akathisia
  • B. Hallucinations
  • C. Orthostatic hypotension
  • D. Drowsiness
Correct Answer: C

Rationale: The correct side effect that the nurse should monitor for in an elderly client diagnosed with delirium and treated with antipsychotic medication is orthostatic hypotension. Antipsychotic medications can lead to a drop in blood pressure upon standing, particularly in elderly individuals. Akathisia (choice A) refers to a movement disorder characterized by a feeling of inner restlessness and a compelling need to be in constant motion, which can be a side effect of antipsychotic medications but is not specific to elderly clients with delirium. Hallucinations (choice B) are sensory perceptions that appear real but are created by the mind, and while they can be associated with certain conditions or medications, they are not a common side effect of antipsychotic medications in elderly clients with delirium. Drowsiness (choice D) is a general CNS depressant effect that can occur with antipsychotic medications but is not the specific side effect that the nurse should be monitoring for in this case.

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Which client statement suggests that the client is using a defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit?

  • A. At least I hit the wall instead of hitting the psychiatric aide.
  • B. I am here because the police thought I was doing something wrong.
  • C. I want to be here because I know it is the best psychiatric facility.
  • D. Don't believe everything my family tells you, I am not crazy.
Correct Answer: A

Rationale: The correct answer is A because the client is projecting their own aggressive tendencies onto the psychiatric aide by suggesting hitting the wall instead of the aide. This statement reflects projection, a defense mechanism where one attributes their unacceptable feelings or impulses to others. Choice B reflects externalization rather than projection, Choice C reflects rationalization, and Choice D reflects denial.

The RN on the evening shift receives a report that a client is scheduled for electroconvulsive treatment (ECT) in the morning. Which intervention should the RN implement the evening before the scheduled ECT?

  • A. Hold all bedtime medications.
  • B. Keep the client NPO after midnight.
  • C. Implement elopement precautions.
  • D. Give the client an enema at bedtime.
Correct Answer: B

Rationale: Keeping the client NPO after midnight is the appropriate intervention before ECT to prevent complications during the procedure. Withholding food and fluids reduces the risk of aspiration and helps ensure the safety of the client. Option A (Hold all bedtime medications) is incorrect because medications may need to be given as prescribed unless specified otherwise by the healthcare provider. Option C (Implement elopement precautions) is unrelated to preparing a client for ECT and focuses on preventing a client from leaving the treatment area. Option D (Give the client an enema at bedtime) is unnecessary and not a standard pre-ECT preparation, making it an incorrect choice.

An adolescent client is admitted to the psychiatric unit for self-harming behaviors. Which of the following is a priority nursing intervention?

  • A. Assess the client's suicidal ideation.
  • B. Educate the client about healthy coping mechanisms.
  • C. Encourage family therapy sessions.
  • D. Provide a safe environment free of potential self-harm tools.
Correct Answer: D

Rationale: The priority nursing intervention for an adolescent admitted for self-harming behaviors is to provide a safe environment free of potential self-harm tools. This intervention aims to prevent immediate harm to the client. Assessing suicidal ideation is important but ensuring physical safety takes precedence. While educating about healthy coping mechanisms is crucial for long-term management, immediate safety is the priority. Family therapy sessions are beneficial for holistic care but are not the immediate priority when the client's safety is at risk.

A client with postpartum depression receives a prescription for sertraline (Zoloft). What information is most important to include in client teaching?

  • A. Avoid foods high in tyramine, such as processed meats, red wine, and Swiss cheese.
  • B. Contact the healthcare provider immediately if suicidal thoughts occur.
  • C. Increase activity level to include regular exercise.
  • D. Contact the healthcare provider immediately if muscle stiffness occurs.
Correct Answer: B

Rationale: The most critical information to include in client teaching for a client with postpartum depression starting sertraline (Zoloft) is to contact the healthcare provider immediately if suicidal thoughts occur. This is vital for the client's safety as antidepressants, including sertraline, can sometimes increase the risk of suicidal thoughts, especially at the start of treatment. Choices A, C, and D are not the most crucial information in this scenario. Choice A about avoiding foods high in tyramine is not directly related to sertraline use. Choice C about increasing activity level is important but not as critical as addressing suicidal ideation. Choice D about muscle stiffness is a potential side effect of sertraline but is not as urgent as monitoring for suicidal thoughts.

A client with schizophrenia is exhibiting visual and auditory hallucinations. What should be the RN's initial intervention?

  • A. Instruct the client to ignore the hallucinations.
  • B. Encourage the client to describe the hallucinations in detail.
  • C. Assess the client's perception of the hallucinations.
  • D. Provide reassurance that the hallucinations are not real.
Correct Answer: C

Rationale: The correct initial intervention for a client with schizophrenia exhibiting visual and auditory hallucinations is to assess the client's perception of the hallucinations. This step is crucial as it helps the RN determine the severity of the hallucinations and the best course of action for management and intervention. Instructing the client to ignore the hallucinations (Choice A) may not be effective as the hallucinations may be distressing and overwhelming. Encouraging the client to describe the hallucinations in detail (Choice B) may potentially worsen the symptoms or trigger further distress. Providing reassurance that the hallucinations are not real (Choice D) may not be appropriate as the client may genuinely believe in their reality, and this reassurance may not address the underlying issues causing the hallucinations.

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