HESI EAQ Mental Health Level 2
What client behavior indicates to the nurse that a client with schizophrenia, undifferentiated type, is improving and that the client's plan of care can be updated? 1 Avoids other clients 2 Expresses negative feelings freely 3 Describes delusions in meticulous detail 4 Communicates with others in an organized manner
Communicates with others in an organized manner The presence of loosely associated tangential thinking is one of the cardinal symptoms of schizophrenia; its lessening will demonstrate improvement. Avoiding other clients may reflect a withdrawal from reality and does not necessarily signal improvement. Most clients with schizophrenia are able to express negative feelings freely because control by the ego is ineffective. Describing delusions in detail does not demonstrate improvement; paranoid delusions are usually well organized and on the surface often seem logical.
One afternoon the nurse on the unit overhears a young female client having an argument with her boyfriend. A while later the client complains to the nurse that dinner is always late and the meals are terrible. The nurse identifies the defense mechanism that the client is using as: 1 Projection 2 Dissociation 3 Displacement 4 Intellectualization
Displacement Displacement reduces anxiety by transferring the emotions associated with an object or person to another emotionally safer object or person. Projection is the attempt to deal with unacceptable feelings by attributing them to another. Dissociation is an attempt to detach emotional involvement or the self from an interaction or the environment. Intellectualization is the use of facts or other logical reasoning rather than feelings to deal with the emotional effect of a problem; it is a form of denial.
What therapeutic nursing intervention may redirect a hyperactive, manic client? 1 Suggesting that the client write a short story 2 Having the client initiate group social activities on the unit 3 Asking the client to guide other clients as they clean their rooms 4 Encouraging the client to tear pictures out of magazines for a scrapbook
Encouraging the client to tear pictures out of magazines for a scrapbook Physical activity will help the client expend some of the excess energy without requiring him to make decisions or forcing other clients to deal with the behavior. The client's extreme activity limits his capacity for concentration or task completion. The client may disrupt the unit because of the excess activity and bossiness associated with this disorder. The client needs guidance and is not able to guide others.
The following data is recorded during the assessment of a client being treated in the emergency department for minor injuries resulting from a mugging and robbery. In light of this information, the nurse initially: 1 Encourages the client to breathe deeply to minimize anxious feelings 2 Explains that feeling anxious is a common response to such an experience 3 Keeps the auditory and visual stimuli in the client's environment to a minimum 4 Assigns unlicensed assistive personnel to remain with the client to prevent falls
Explains that feeling anxious is a common response to such an experience The initial intervention is to help the client identify and deal with the emotional and physical reactions to the recent trauma. Providing this information about the anxiety being experienced will facilitate the process of relaxation for the client. Encouraging deep breathing and other relaxation techniques and creating a low-stimulus environment are appropriate in cases of anxiety, but these are not the initial interventions in this situation. Although addressing safety issues is appropriate in cases of anxiety-induced dizziness, dedicating a staff member to that task is neither realistic nor necessary in this situation.
Rehabilitation of a client with chronic obstructive pulmonary disease (COPD) involves strategies to decrease hospital admissions and to live a more active life. What should the nurse teach the client to do Initiate activities to eliminate infection. 2 Inhale during movements that require energy. 3 Implement breathing that uses the thoracic muscles. 4 Incorporate humidification into the home environment.
Incorporate humidification into the home environment. Humidification of the environment helps to prevent thickened secretions. Liquefied secretions are easier to expectorate. Measures to prevent infection are essential; however, infections are impossible to eliminate. Exhaling requires less energy than inhaling; therefore, movements that use energy should be done during exhalation. The use of abdominal muscles rather than thoracic muscles improves the client's breathing.
A nurse working on a mental health unit is caring for several clients who are at risk for suicide. Which client is at the greatest risk for successful suicide? 1 Young adult who is acutely psychotic 2 Adolescent who was recently sexually abused 3 Older single man just found to have pancreatic cancer 4 Middle-age woman experiencing dysfunctional grieving
Older single man just found to have pancreatic cancer Older single men with chronic health problems are at the highest risk of suicide. This is because men have fewer social supports than women do. (Men are less social then women in general.) Less social support at times of stress can increase the risk of suicide. Also, chronic health problems can lead to learned helplessness, which can lead to depression. People who are acutely psychotic as a group are at higher risk for suicide, but they do not have the suicide rate of older single adult men with chronic health problems. An adolescent who was recently sexually abused, although severely traumatized, does not have the risk of suicide of an elderly single man with chronic health problems. Dysfunctional grieving is prolonged grieving that is characterized by greater disability and dysfunctional patterns of behavior. Although people with complicated dysfunctional grieving may be at risk for self-directed violence, they do not have the suicide risk of elderly single men with chronic health problems.
What is a frequent finding in clients with paraphiliac disorders? Other covert or overt emotional problems 2 Gonadal and pituitary hormone deficiencies 3 Overassociation with society's fringe groups 4 Inadequate development of the sexual organs
Other covert or overt emotional problems Clients with paraphiliac disorders usually have many other emotional problems, either overt or covert in nature. There is no proof of a deficiency of gonadal and pituitary hormones in connection with paraphiliac disorders. A link between overassociation with society's fringe groups and paraphiliac disorders has no basis in fact. Sexual organs in individuals with paraphiliac sexual disorders are not inadequately developed.
A nurse is teaching a group of recently hired staff members about conscious and unconscious defense mechanisms that are used to defend the self against anxiety. What is an example of a conscious defense mechanism that the nurse should include? 1 Undoing 2 Projection 3 Suppression 4 Intellectualization
Suppression Suppression is a conscious measure used as a defense against anxiety; the affected person intentionally avoids thinking about disturbing problems, wishes, feelings, or experiences. Undoing is an unconscious defense mechanism; it is the use of words or behavior to make amends symbolically for unacceptable thoughts, feelings, or actions. Projection is an unconscious defense mechanism; it is the false attribution to others of one's own unacceptable impulses, feelings, attitudes, or thoughts. Intellectualization is an unconscious defense mechanism; it is the use of thinking, ideas, or intellect to avoid emotionally charged feelings.
A female client terminally ill with cancer says to the nurse, "My husband is avoiding me. He doesn't love me anymore because of this awful tumor!" What is the nurse's most appropriate response? 1 "What makes you think he doesn't love you?" 2 "Avoidance is a defense. He needs your help to cope." 3 "Do you think he's having difficulty dealing with your illness?" 4 "You seem very upset. Tell me how your husband is avoiding you."
You seem very upset. Tell me how your husband is avoiding you. The response "You seem very upset. Tell me how your husband is avoiding you" validates the client's feelings and encourages the client to look at the basis or reality of the expressed concern. The response "What makes you think he doesn't love you?" ignores the client's statement; the client has already told the nurse the basis for the feelings. The response "Avoidance is a defense. He needs your help to cope" puts the responsibility for the husband's behavior on the client, who may not be able to handle it. The husband may or may not be having difficulty dealing with the client's illness, and this question does not focus on the client's feelings.
