Mental Health Final HESI

A client experiences expressive aphasia as a result of a brain attack (cerebrovascular accident, CVA). The client's spouse asks whether the client's speech will ever return. What is the best response by the nurse?

"It is hard to say how much improvement will occur." Recovery from aphasia is a continuous process; the amount of recovery cannot be predicted. The response "It should return in several months" gives false reassurance; it may take a year or longer or may never return. The response "You will have to ask the primary healthcare provider" abdicates the nurse's responsibility; the healthcare provider cannot predict return of function. Speech return is a continuous process; it may take a year or longer or may never return.

When planning nursing care for clients who are grieving the potential death of a family member, it is helpful to draw on the understanding of the five stages of grieving identified and described by Elisabeth Kübler-Ross. Place these stages in order of progression from first to last.

1.Denial 2.Anger 3.Bargaining 4.Depression 5.Acceptance Initially when someone is coping with grief there is a refusal to believe that the loss has occurred or is going to occur (denial), and individuals are in a state of shock. As awareness of the loss increases, people usually become angry and cannot understand why this is happening. Coping then moves into the stage of bargaining, in which the dying or grieving person attempts to avoid the loss by gaining more time. This is followed by depression, when what has happened becomes undeniable. Finally individuals may progress to the stage of acceptance after coming to terms with the loss. *Test-Taking Tip: Make educated guesses when necessary.

A transfusion of packed red blood cells is prescribed for a client with anemia. List the following actions in the order in which they should be performed by the nurse.

1.Ensure that the client signed a consent for the transfusion. 2.Determine the client's vital signs. 3.Compare the number on the blood product and laboratory record. 4.Don a pair of clean gloves. 5.Run the transfusion slowly. A client must sign a consent for the transfusion before the procedure; clients have the right to refuse. Vital signs should be obtained immediately before the transfusion to serve as a baseline for comparison if a reaction is suspected. Two nurses must verify that the numbers, ABO type, and Rh type on the blood label and laboratory record match before hanging the transfusion to minimize risk of transfusion reactions. Clean gloves must be worn before inserting the spike of the blood administration set. The transfusion is run slowly for the first 15 to 20 minutes, but only after other steps have been completed. *Test-Taking Tip: Answer the question that is asked. Read the situation and the question carefully, looking for key words or phrases. Do not read anything into the question or apply what you did in a similar situation during one of your clinical experiences. Think of each question as being an ideal, yet realistic, situation.

A client is scheduled for surgery to repair an irreducible (incarcerated) hernia. What nursing intervention is of primary importance?

Assessing the client's bowel movementA possible complication of a hernia is intestinal obstruction. If an obstruction occurs, there is no passage of flatus or bowel movements. The supine position will have no effect on an incarcerated hernia. Checking the client's vital signs periodically is done for all clients; it is not specific for a client with a hernia and is not the primary assessment. Monitoring the client's serum enzyme levels will not facilitate the identification of complications.

A 3-year-old child's parents have been unable to visit since the child was admitted to the hospital. The toddler has become quiet and withdrawn. To best help the child at this time, what should the nurse do?

Assign the same nurse to care for the child whenever possible. Assigning the same nurse when possible ensures the presence of a familiar, consistent caregiver with whom the child can relate. Bringing the child a stuffed animal may provide some comfort, but the child needs to receive love and attention from an adult. Encouraging the parents to visit may increase the parents' guilt and anxiety; the data given indicate that the parents have been unable, not unwilling, to visit the child. Playing games with other children may provide some comfort, but the child still needs to receive love and attention from an adult.

While interacting with a client who reported visual changes, the nurse finds that the client is frequently exposed to the sun. Which conditions might this client have? Select all that apply.

Cataracts, Pterygium, Pinguecula. Cataracts develop when oxidative damage to the lens occurs due to chronic exposure to ultraviolet light. Pterygium (a thickened, triangular bit of pale tissue that extends from the inner canthus to the nasal border of the cornea) is caused by chronic sun exposure. Biochemical changes in the lens protein causes pinguecula, which is a small yellowish spot usually on the medial aspect of the conjunctiva. This condition is caused by tissue damage related to chronic exposure to ultraviolet light. Entropion is a condition characterized by changes in the eyelid, which occurs due to a loss of orbital fat and decreased muscle tone. Arcus senilis is caused by excess cholesterol deposits on the cornea. *Test-Taking Tip: Ultraviolet rays emitted by the sun may have damaging effects on the visual system. Chronic exposure to UV rays may affect the conjunctiva and lens.

Clients addicted to alcohol often use the defense mechanism of denial. What is the reason that this defense is so often used?

It reduces their feelings of guilt. Alcoholic clients often use denial as a defense against feelings of guilt; this reduces anxiety and protects the self. Denial may make a client seem more stable to others, not independent. Denial deals more with a client's own expectations. Looking better in the eyes of others may be part of the reason, but the bigger motivating factor is to ease guilt feelings. *Test-Taking Tip: Eat breakfast or lunch before an exam. Avoid greasy, heavy foods and overeating. This will help keep you calm and give you energy.

Which hormones are secreted by the posterior pituitary gland? Select all that apply.

Oxytocin and antidiuretic hormone. Oxytocin and antidiuretic hormone (vasopressin) are secreted by the posterior pituitary gland. Prolactin, corticotropin, and melanocyte-stimulating hormones are secreted by the anterior pituitary gland.

After assessing a victim of a bomb blast that has caused mass casualties, the emergency department nurse applies a black band to the hand. What is the rationale behind this nursing action?

The victim has severe head injury and requires artificial ventilation. A black tag should be given to victims of a disaster who are expected to die. A severe head injury and need for artificial ventilation indicates a low chance of survival. Blood pressure of 110/80 mm Hg is a normal finding. Clients who can ambulate without assistance would be given a green tag. A yellow band is applied to the victims with large wounds who require treatment within 2 hours. *Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options.

What is the middle layer of the eyeball?

Uveal tract. The uveal tract (which consists of the iris, choroid, and ciliary body) is considered the middle layer of the eyeball. The sclera is a part of the tough outer layer of the eyeball. The retina is the innermost layer of the eyeball. The outermost layer of the eyeball consists of the transparent cornea.