Mental Health Hesi quiz
The community health nurse talks to a male client who has bipolar disorder. The client explains that he sleeps 4 to 5 hours a night and is working with his partner to start two new businesses and build an empire. The client stopped taking his medications several days ago. What nursing problem has the highest priority?A) Excessive work activity.B) Decreased need for sleep.C) Medication management.D) Inflated self-esteem. The most important nursing problem is medication management (C) because compliance with the medication regimen will help prevent hospitalization. The client is also exhibiting signs of (A, B, and C); however, these problems do not have the priority of medication management.Correct Answer(s): C
medication management The priority is to teach the parents that their son will need monitoring and support during withdrawal (D) to ensure that he does not attempt suicide. Although (A and C) are true, they are not as relevant to the parent's expressed concern. There is no information to support (B).
Based on non-compliance with the medication regimen, an adult client with a medical diagnosis of substance abuse and schizophrenia was recently switched from oral fluphenazine HCl (Prolixin) to IM fluphenazine decanoate (Prolixin Decanoate). What is most important to teach the client and family about this change in medication regimen?A) Signs and symptoms of extrapyramidal effects (EPS).B) Information about substance abuse and schizophrenia.C) The effects of alcohol and drug interaction.D) The availability of support groups for those with dual diagnoses.
the effects of alcohol and drug interaction Alcohol enhances the EPS side effects of Prolixin. The half-life of Prolixin PO is 8 hours, whereas the half-life of the Prolixin Decanoate IM is 2 to 4 weeks. That means the side effects of drinking alcohol are far more severe when the client drinks alcohol after taking the long-acting Prolixin Decanoate IM. (A, B, and D) provide valuable information and should be included in the client/family teaching, but they do not have the priority of (C).
A 45-year-old female client is admitted to the psychiatric unit for evaluation. Her husband states that she has been reluctant to leave home for the last six months. The client has not gone to work for a month and has been terminated from her job. She has not left the house since that time. This client is displaying symptoms of what condition?A) Claustrophobia.B) Acrophobia.C) Agoraphobia.D) Post-traumatic stress disorder.
Agoraphobia Agoraphobia (C) is the fear of crowds or being in an open place. (A) is the fear of being in closed places. (B) is the fear of high places. Remember, a phobia is an unrealistic fear which is associated with severe anxiety. (D) consists of the development of anxiety symptoms following a life event that is particularly serious and stressful (war, witnessing a child killed, etc.) and is experienced with terror, fear, and helplessness--a phobia is different.
A 65-year-old female client complains to the nurse that recently she has been hearing voices. What question should the nurse ask this client first?A) Do you have problems with hallucinations?B) Are you ever alone when you hear the voices?C) Has anyone in your family had hearing problems?D) Do you see things that others cannot see?
Are you ever alone when you hear the voices Determining if the client is alone when she hears voices (B) will assist in differentiating between hallucinations and hearing loss; this is especially important in the aging population. If the client is experiencing hallucinations, the voices will be real to her, and it is unlikely that (A) would provide accurate information. (C and D) might be good follow-up questions, but would not have the priority of (B).
The nurse is planning care for a 32-year-old male client diagnosed with HIV infection who has a history of chronic depression. Recently, the client's viral load has begun to increase rather than decrease despite his adherence to the HIV drug regimen. What should the nurse do first while taking the client's history upon admission to the hospital?A) Determine if the client attends a support group weekly.B) Hold all antidepressant medications until further notice.C) Ask the client if he takes St. John's Wort routinely.D) Have the client describe any recent changes in mood.
Ask the client if he takes St. John's Wort routinely St. John's Wort, an herbal preparation, is an alternative (nonconventional) therapy for depression, but it may adversely interact with medications used to treat HIV infection (C). The nurse's top priority upon admission is to determine if the client has been taking this herb concurrently with HIV antiviral drugs, which may explain the rise in the viral load. Asking about (A or D) may be helpful in gathering more data about the client's depressive state, but these issues do not have the priority of (C). (B) may be harmful to the client.
A client who is known to abuse drugs is admitted to the psychiatric unit. Which medication should the nurse anticipate administering to a client who is exhibiting benzodiazepine withdrawal symptoms?A) Perphenazine (Trilafon).B) Diphenhydramine (Benadryl).C) Chlordiazepoxide (Librium).D) Isocarboxazid (Marplan).
Chlordiazepoxide (Librium) Librium (C), an antianxiety drug, as well as other benzodiazepines, are used in titrated doses to reduce the severity of abrupt benzodiazepine withdrawal. (A) is an antipsychotic agent. (B) is an antihistamine and antianxiety drug. (D) is an MAO inhibitor.
A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care?A) Client will not demonstrate cross-addiction.B) Co-dependent behaviors will be decreased.C) Excessive CNS stimulation will be reduced.D) Client's level of consciousness will increase.
Excessive CNS stimulation will be reduced Substitution therapy with another CNS depressant is intended to decrease the excessive CNS stimulation that can occur during benzodiazepine withdrawal (C). (A, B, and D) are all appropriate outcome statements for the client described, but do not have the priority of (C).
An adult male client who was admitted to the mental health unit yesterday tells the nurse that microchips were planted in his head for military surveillance of his every move. Which response is best for the nurse to provide?A) You are in the hospital, and I am the nurse caring for you.B) It must be difficult for you to control your anxious feelings.C) Go to occupational therapy and start a project.D) You are not in a war area now; this is the United States.
Go to occupational therapy and start a project Delusions often generate fear and isolation, so the nurse should help the client participate in activities that avoid focusing on the false belief and encourage interaction with others (C). Delusions are often well-fixed, and though (A) reinforces reality, it is argumentative and dismisses the client's fears. It is often difficult for the client to recognize the relationship between delusions and anxiety (B), and the nurse should reassure the client that he is in a safe place. Dismissing delusional thinking (D) is unrealistic because neurochemical imbalances that cause positive symptoms of schizophrenia require antipsychotic drug therapy.
A client on the psychiatric unit appears to imitate a certain nurse on the unit. The client seeks out this particular nurse and imitates her mannerisms. The nurse knows that the client is using which defense mechanism?A) Sublimation.B) Identification.C) Introjection.D) Repression.
Identification Identification (B) is an attempt to be like someone or emulate the personality traits of another. (A) is substituting an unacceptable feeling for one that is more socially acceptable. (C) is incorporating the values or qualities of an admired person or group into one's own ego structure. (D) is the involuntary exclusion of painful thoughts or memories from one's awareness.
The nurse is assessing the parents of a nuclear family who are attending a support group for parents of adolescents. According to Erikson, these parents who are adapting to middle adulthood should exhibit which characteristic?A) Loss of independence.B) Increased self-understanding.C) Isolation from society.D) Development of intimate relationships.
Increased self-understanding Middle adulthood is characterized by self-reflection, understanding, and acceptance (B), and generativity or guidance of children. (A and C) are maladaptive behaviors in middle adulthood. Although middle-aged adults may delay or re-establish intimate relationships, (D) is initially developed during young adulthood.
The wife of a male client recently diagnosed with schizophrenia asks the nurse, "What exactly is schizophrenia? Is my husband all right?" Which response is best for the nurse to provide to this family member?A) It sounds like you're worried about your husband. Let's sit down and talk.B) It is a chemical imbalance in the brain that causes disorganized thinking.C) Your husband will be just fine if he takes his medications regularly.D) I think you should talk to your husband's psychologist about this question.
It is a chemical imbalance in the brain that causes disorganized thinking The nurse should answer the client's question with factual information and explain that schizophrenia is a chemical imbalance in the brain (B). (A) is a therapeutic response but does not answer the question, and may be an appropriate response after the nurse answers the question asked. Although (C) is likely true to some degree, it is also true that some clients continue to have disorganized thinking even with antipsychotic medications. Referring the spouse to the psychologist (D) is avoiding the issue; the nurse can and should answer the question.
A male client is admitted to a mental health unit on Friday afternoon and is very upset on Sunday because he has not had the opportunity to talk with the healthcare provider. Which response is best for the nurse to provide this client?A) Let me call and leave a message for your healthcare provider.B) The healthcare provider should be here on Monday morning.C) How can I help answer your questions?D) What concerns do you have at this time?
Let me call and leave a message for your healthcare provider It is best for the nurse to call the healthcare provider (A) because clients have the right to information about their treatment. Suggesting that the healthcare provider will be available the following day (B) does not provide immediate reassurance to the client. The nurse can also implement offer to assist the client (C and D), but the highest priority intervention is contacting the healthcare provider.
The charge nurse is collaborating with the nursing staff about the plan of care for a client who is very depressed. What is the most important intervention to implement during the first 48 hours after the client's admission to the unit?A) Monitor appetite and observe intake at meals.B) Maintain safety in the client's milieu.C) Provide ongoing, supportive contact.D) Encourage participation in activities.
Maintain safety in the client's milieu The most important reason for closely observing a depressed client immediately after admission is to maintain safety (B), since suicide is a risk with depression. (A, C, and D) are all important interventions, but safety is the priority.
The nurse is conducting discharge teaching for a client with schizophrenia who plans to live in a group home. Which statement is most indicative of the need for careful follow-up after discharge?A) Crickets are a good source of protein.B) I have not heard any voices for a week.C) Only my belief in God can help me.D) Sometimes I have a hard time sitting still.
Only my belief in God can help me The most frequent cause of increased symptoms in psychotic clients is non-compliance with the medication regimen. If clients believe that "God alone" is going to heal them (C), then they may discontinue their medication, so (C) would pose the greatest threat to this client's prognosis. (A) would require further teaching, but is not as significant a statement as (C). (B) indicates an improvement in the client's condition. (D) may be a sign of anxiety that could improve with treatment, but does not have the priority of (C).
On admission to a residential care facility, an elderly female client tells the nurse that she enjoys cooking, quilting, and watching television. Twenty-fours after admission, the nurse notes that the client is withdrawn and isolated. It is best for the nurse to encourage this client to become involved in which activity?A) Clean the unit kitchen cabinets.B) Participate in a group quilting project.C) Watch television in the activity room.D) Bake a cake for a resident's birthday.
Participate in a group quilting project Peer interaction in a group activity (B) will help to prevent social isolation and withdrawal. (A, C, and D) are activities that can be accomplished alone, without peer interaction.
Which diet selection by a client who is depressed and taking the MAO inhibitor tranylcypromine sulfate (Parnate) indicates to the nurse that the client understands the dietary restrictions imposed by this medication regimen?A) Hamburger, French fries, and chocolate milkshake.B) Liver and onions, broccoli, and decaffeinated coffee.C) Pepperoni and cheese pizza, tossed salad, and a soft drink.D) Roast beef, baked potato with butter, and iced tea.
Roast beef, baked potato with butter, and iced tea. Only (D) contains no tyramine. Tyramine in foods interacts with MAOI in the body causing a hypertensive crisis which is life-threatening, and Parnate is classified as an MAOI antidepressant. Some items in (A, B, and C) contain tyramine and would not be permitted for a client taking Parnate.
The nurse observes a client who is admitted to the mental health unit and identifies that the client is talking continuously, using words that rhyme but that have no context or relationship with one topic to the next in the conversation. This client's behavior and thought processes are consistent with which syndrome?A) Dementia.B) Depression.C) Schizophrenia.D) Chronic brain syndrome.
Schizophrenia The client is demonstrating symptoms of schizophrenia (C), such as disorganized speech that may include word salad (communication that includes both real and imaginary words in no logical order), incoherent speech, and clanging (rhyming). Dementia (A) is a global impairment of intellectual (cognitive) functions that may be progressive, such as Alzheimer's or organic brain syndrome (D). Depression (C) is typified by psychomotor retardation, and the client appears to be slowed down in movement, in speech, and would appear listless and disheveled.
An elderly female client with advanced dementia is admitted to the hospital with a fractured hip. The client repeatedly tells the staff, "Take me home. I want my Mommy." Which response is best for the nurse to provide?A) Orient the client to the time, place, and person.B) Tell the client that the nurse is there and will help her.C) Remind the client that her mother is no longer living.D) Explain the seriousness of her injury and need for hospitalization.
Tell the client that the nurse is there and will help her Those with dementia often refer to home or parents when seeking security and comfort. The nurse should use the techniques of "offering self" and "talking to the feelings" to provide reassurance (B). Clients with advanced dementia have permanent physiological changes in the brain (plaques and tangles) that prevent them from comprehending and retaining new information, so (A, C, and D) are likely to be of little use to this client and do not help the client's emotional needs.
Which statement about contemporary mental health nursing practice is accurate?A) There is one approved theoretical framework for psychiatric nursing practice.B) Psychiatric nursing has yet to be recognized as a core mental health discipline.C) Contemporary practice of psychiatric nursing is primarily focused on inpatient care.D) The psychiatric nursing client may be an individual, family, group, organization, or community.
The psychiatric nursing client may be an individual, family, group, organization, or community. Mental health nursing is not only concerned with one-on-one interactions. Psychiatric stressors can impact and be reflected in the overall direction, activities, and responses involving families, groups, and entire communities (D). (A, B, and C) are incorrect statements about the status of mental health nursing.
A female client with depression attends group and states that she sometimes misses her medication appointments because she feels very anxious about riding the bus. Which statement is the nurse's best response?A) Can your case manager take you to your appointments?B) Take your medication for anxiety before you ride the bus.C) Let's talk about what happens when you feel very anxious.D) What are some ways that you can cope with your anxiety?
What are some ways that you can cope with your anxiety The best response is to explore ways for the client to cope with anxiety (D). The nurse should encourage problem-solving rather than dependence on the case manager (A) for transportation. Strategies for coping with anxiety should be encouraged before suggesting (B). (C) is therapeutic, but the best response is an open-ended question to explore ways to cope with the anxiety.
