RN Hesi Mental Health

RN Hesi Mental Health Related

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History and Physical
The client is in the hospital after her house collapsed during a hurricane. She has been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue monitoring her respiratory function and to complete intravenous antibiotic administration. Nurses' Notes
0900
Pain assessment completed. The client's pain is 2/10. The client requests sleeping medication for the night. She states that she has horrible thoughts and memories about the house collapsing all the time and that it is keeping her from falling asleep. She states, "I used to be so happy before all of this happened. Now I can't seem to get out of this funk I am in." The client would also prefer to be in a quieter area of the unit as she is currently by the nurses' station and hears talking and alarms constantly.

The client is in the hospital after her house collapsed during a hurricane. She has been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue monitoring her respiratory function and to complete intravenous antibiotic administration. The nurse engages the client in conversation about her feelings and some of her coping mechanisms. Click to specify which client statement or behavior is most likely associated with each of the listed defense mechanisms.

  • A. The client discusses moving to Hawaii instead of returning to rebuild her house. (Fantasy)
  • B. The client seems unemotional when talking about needing to rebuild her house. (Isolation)
  • C. The client states that she sometimes forgets why she is in the hospital. (Suppression)
  • D. The client is frightened that the hospital will burn down. (Denial)
Correct Answer: A,B,C,D

Rationale: Fantasy (Hawaii move) escapes reality, isolation (unemotional) separates emotions, suppression (forgetting hospitalization) avoids distress, and denial (hospital fire fear) projects trauma.

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The nurse is teaching a client with cancer about skincare for the portal site receiving external beam radiation. Which client action regarding skin care indicates a need for further teaching?

  • A. Applies prescribed lotions to the radiation site.
  • B. Washes the radiation site with antibacterial soap and water.
  • C. Wears clothing to cover the radiation site.
  • D. Dries the area with patting motions after taking a shower.
Correct Answer: B

Rationale: Washing with antibacterial soap is too harsh for the radiation site, indicating a need for further teaching. Prescribed lotions, protective clothing, and patting to dry are appropriate.

The nurse is assessing a client whose spouse died of a stroke two weeks ago and who reports having numbness and tingling on the right side of the body. The nurse should consider the client's symptoms may likely be due to which condition.

  • A. Preoccupation.
  • B. Reexperience.
  • C. Somatization.
  • D. Disorganization.
Correct Answer: C

Rationale: Somatization involves psychological distress manifesting as physical symptoms like numbness and tingling, likely due to grief. Other options are less applicable.

Which intervention(s) should the nurse include in the plan of care for an adolescent who is depressed? (Select all that apply.)

  • A. Restrict visitors to family members only.
  • B. Discuss the client's suicide plan.
  • C. Limit time allowed to play video games.
  • D. Encourage the client to discuss thoughts and feelings about wanting to die.
  • E. Reinforce statements regarding a will to live and realistic plans for the future.
Correct Answer: B,D,E

Rationale: Discussing suicide plans, encouraging expression of suicidal thoughts, and reinforcing hope are critical for safety and therapeutic support. Restricting visitors or limiting video games are less relevant.

A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?

  • A. Assist the client with relaxation techniques in the group.
  • B. Escort the client from the group to reduce stimuli.
  • C. Provide education about ways to cope with anxiety.
  • D. Ask the client to describe and identify the source of the feelings.
Correct Answer: A

Rationale: Assisting with relaxation techniques in the group provides immediate anxiety relief and support, suitable for acute anxiety.

The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?

  • A. Complete a thorough room search to ensure the client does not have access to objects that can be used for self-harm.
  • B. Provide the client time alone in the client's room to reduce external stimulation and promote relaxation.
  • C. Alert the assigned staff to closely monitor the client and intervene as needed to reduce the risk of self-mutilation.
  • D. Give the client firm, consistent expectations that self-mutilating behaviors are unacceptable and will not be allowed.
Correct Answer: C

Rationale: Close monitoring and intervention are critical to prevent self-harm in a client showing signs of distress, prioritizing safety.

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