Quizlet Mental Health HESI

Quizlet Mental Health HESI Related

Review Quizlet Mental Health HESI related questions and content

Kyle, a patient with schizophrenia, began taking the first-generation antipsychotic haloperidol (Haldol) last week. One day you find him sitting very stiffly and not moving. He is diaphoretic, and when you ask if he is okay, he seems unable to respond verbally. His vital signs are: BP 170/100, P 110, T 104.2°F. What is the priority nursing intervention? Select all that apply.

  • A. Hold his medication and contact his prescriber.
  • B. Wipe him with a washcloth wet with cold water or alcohol.
  • C. Administer a medication such as benztropine IM to correct this dystonic reaction.
  • D. Reassure him that although there is no treatment for his tardive dyskinesia, it will pass.
Correct Answer: C

Rationale: The correct intervention is to administer a medication such as benztropine IM to correct this dystonic reaction. The presentation of stiffness, diaphoresis, inability to respond verbally, and vital sign changes suggest an acute dystonic reaction, which is an extrapyramidal side effect of antipsychotic medications like haloperidol. Benztropine is an anticholinergic medication commonly used to manage these acute dystonic reactions. Option A is incorrect because holding the medication without addressing the acute symptoms may lead to worsening of the condition. Option B is incorrect as wiping with cold water or alcohol does not address the underlying cause of the symptoms. Option D is incorrect because it mentions tardive dyskinesia, which is a different condition characterized by involuntary movements that occur with long-term antipsychotic use, not the acute dystonic reaction seen here.

You may also like to solve these questions

A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit's day room. What action should the nurse implement first?

  • A. Administer a PRN sedative.
  • B. Sit in the chair next to the client.
  • C. Escort the client to his room.
  • D. Listen to what the client is saying.
Correct Answer: D

Rationale: When dealing with a client experiencing auditory hallucinations, it is crucial for the nurse to first listen to what the client is saying. Auditory hallucinations may hold significance to the client, and by actively listening, the nurse can gather information about the content and context of the hallucinations. This information helps the nurse assess the client's current state, emotional responses, and the potential triggers for the behavior. Administering a PRN sedative (Choice A) should not be the initial action as it may suppress important information and feelings the client is trying to communicate. Sitting next to the client (Choice B) may not be appropriate without understanding the situation better. Escorting the client to his room (Choice C) may escalate the situation without addressing the underlying cause of the behavior, which can be better understood through active listening.

The client states, "It seems strange that I don't have a TV in my room." Which statement would be best for the nurse to provide?

  • A. You can watch TV as much as you want outside of your room.
  • B. Sometimes clients feel like the TV is sending them messages.
  • C. It's important to be out of your room and talking to others.
  • D. Watching TV is a passive activity and we want you to be active.
Correct Answer: B

Rationale: The correct answer is B because clients with depression or psychosis may interpret TV as sending messages, so it is often removed to prevent this risk. Choice A is incorrect because it does not address the client's concern and may not be feasible. Choice C is incorrect because it diverts from the client's immediate issue regarding the TV. Choice D is incorrect because it does not address the client's specific concern and instead focuses on the activity level.

A client with depression remains in bed most of the day and declines activities. Which nursing problem has the greatest priority for this client?

  • A. Loss of interest in diversional activity.
  • B. Social isolation.
  • C. Refusal to address nutritional needs.
  • D. Low self-esteem.
Correct Answer: C

Rationale: The correct answer is C: 'Refusal to address nutritional needs.' When a client with depression remains in bed and declines activities, addressing their refusal to address nutritional needs is of utmost priority. Nutritional needs are essential for physical health and overall well-being. Inadequate nutrition can worsen the client's physical health, impact their mood, and hinder the effectiveness of treatment. Option A, 'Loss of interest in diversional activity,' while important, is not as critical as addressing nutritional needs for immediate physical well-being. Option B, 'Social isolation,' is a significant concern but addressing nutritional needs takes precedence due to its direct impact on physical health. Option D, 'Low self-esteem,' is a valid concern but does not take priority over addressing the client's refusal to meet their nutritional needs for immediate health benefits.

A teenager who has lost 20 pounds in the last three months is admitted to the hospital with hypotension and tachycardia. The client reports irregular menses and hair loss. Which intervention is most important for the nurse to include in the client plan of care?

  • A. Implement behavior modification therapy.
  • B. Initiate caloric and nutritional therapy.
  • C. Evaluate the client for low self-esteem.
  • D. Record daily weights and graph trends.
Correct Answer: B

Rationale: Initiating caloric and nutritional therapy is the most important intervention for this client due to the significant weight loss and presenting symptoms of hypotension, tachycardia, irregular menses, and hair loss. This intervention aims to address the physical effects of malnutrition and support the client's overall health. Behavior modification therapy (Choice A) may be beneficial in the long term to address underlying issues, but addressing the immediate nutritional needs is a priority. Evaluating the client for low self-esteem (Choice C) is important for holistic care but addressing the physical health concerns takes precedence. Recording daily weights and graphing trends (Choice D) is essential for monitoring progress but does not address the urgent need for nutritional support in this acute situation.

After surgery, a male client with antisocial personality disorder frequently requests a specific nurse be assigned to his care and becomes belligerent when another nurse is assigned. What action should the charge nurse implement?

  • A. Reassure the client that his request will be met whenever possible.
  • B. Advise the client that assignments are not based on client requests.
  • C. Ask the client to explain why he constantly requests the nurse.
  • D. Encourage the client to verbalize his feelings about the nurse.
Correct Answer: B

Rationale: The correct action for the charge nurse is to advise the client that assignments are not based on client requests. Clients with antisocial personality disorder may attempt to manipulate situations to their advantage. By setting clear boundaries and explaining that assignments are not based on client preferences, the nurse helps prevent manipulation and maintains a professional approach to care. Reassuring the client about his requests (Choice A) may encourage the inappropriate behavior to continue. Asking the client to explain his requests (Choice C) may further fuel the manipulation by providing an opportunity for the client to justify his actions. Encouraging the client to verbalize feelings (Choice D) does not address the underlying issue of manipulating the assignment process and may inadvertently reinforce the behavior.

Copyright © 2025 Nokea. All rights reserved.