MENTAL HEALTH HESI

Q1: Child with autism spectrum disorder (ASD). The parents say, "We are going to move our child to a different bedroom in our home." Select the nurse's therapeutic response.

"Children with autism spectrum disorder usually prefer for things to stay the same."

... child with attention deficit disorder. Which statement by the nurse is most appropriate?

"Hug your child after a task is completely performed."

... coping strategies ... clients who are experiencing intimate partner violence...under- standing of the teaching?

"I should try to identify issues that increased my partner's stress level."

Client with anxiety disorder... begins to sweat profusely and breathe rapidly.. & states "I feel like I am having a panic attack." Which response by the nurse is best?

"I'm going to help you back to your room."

Child with autism is admitted to the pediatric unit ... Which response by the nurse is best?

"The inability to maintain eye contact is a characteristic of autism."

... client reporting dizziness and a 'racing heart'.... extremely anxious. Which response by the nurse is best?

"When did you first notice that you were feeling anxious?"

"I am so terrified of heights that the thought of going up my stairs makes me feel like I am going to hyperventilate. I know it sounds ridiculous." Which response is best?

"You feel like your fear does not make sense, but it is very real to you."

A male patient is running ... and keeps repeating, "They are coming!" ... neither follows staff directions nor responds to verbal efforts to calm him. The level of anxiety can be assessed as:

-severe

Alcoholic recovery teaching

1 Expressed accountability: taking responsibility & acknowledging 2 Coping skills 3Setting Goals: develop motivation & self help skills

A client with social anxiety disorder has been struggling with his new job when coworkers invite him to lunch. Which of the following statements indicates the client is improving in coping mechanisms? Select all that apply 1. I went to a restaurant with a few coworkers & focused on our conversation rather than my phobia. 2. I planned to go out of town rather than attend our company's christmas party. 3. I must admit that I am still very nervous about eating in front of my coworkers, but I am working through it. 4. I went to a coffee shop by myself and sat to watch people. 5. I will make excuses to avoid going to eat with my boss.

1, 3, 4

The nurse admits a client for possible appendicitis... client states, "Most days I drink about one pint of vodka."... alcohol withdrawal delirium time frame?

48-72 hours after last consumption

"I am terrified of being outside alone." The nurse should identify that the client is experiencing which of the following phobias?

Agoraphobia

TCA

Amitriptyline and imipramine

Signs of alcohol withdrawal. What assessments will the nurse include when providing care to this client? Select all that apply

Anxiety Tachycardia Irritability Tremors

The nurse provides care for a client diagnosed with alcohol abuse ... Which is the primary goal of counseling?

Assist the client to identify factors that trigger alcohol use

Which of the following ... should the nurse implement ... client in a domestic violence situation? Select all that apply.

Assure the victim that he/she is not alone Preserve any physical evidence, if applicable Convey an attitude of concern and respect for the client

Identification

Attempt to be like someone or emulate the personality, traits, or behaviors of another person

Projection

Attributing one's own thoughts or impulses to another person

Child who plays alone, does not maintain eye contact, repeatedly twists fingers, has inadequate speech, and does not interact with gestures?q\

Autism spectrum disorder (ASD)

Buspirone

Buspar

Treatment for opioid dependence... which of the following medications is used for treatment of opiate withdrawal?

Clonidine Methadone

The nurse finds that a patient who is a drug addict has nasal damage. Which substance does the nurse suspect?

Cocaine

... client who has generalized anxiety disorder and is trembling and pacing during a group activity... Which of the following statements should the nurse make to the client?

Come with me to an area where we can talk without interruption

Reaction formation

Communication or behavior done to negate a previously unacceptable act

A client uses heroin several times a day. Which signs and symptoms does the nurse expect to observe? Select all that apply.

Constricted pupils Depressed respirations Drowsiness or sedation Slurred incoherent speech

... patient with alcohol misuse. What intervention does the nurse plan for rehabilitation of this patient?

Develop motivation and self-help skills

Suppression

Development of conscious attitudes and behaviors that are the opposite of what is really felt

ECT

ECT involves the use of electrically induced seizures for psychiatric purposes. It is used with severely depressed clients who fail to respond to antidepressant medications and therapy. It may be used with extremely suicidal clients because 2 weeks are needed for antidepressants to take effect.

The nurse admits a client who has a diagnosis of alcoholism and admits to drinking a pint of vodka a day.... which intervention is appropriate?

Ensure seizure precautions are in place

The nurse prepares to lead a group session for ... dependence on alcohol. The nurse knows that a client with a diagnosis of alcoholism drinks because of which reason? Select all that apply

Escape from problems Cover up depression or anxiety

A symptom associated with panic attacks is:

Fear of impending doom

Risk factors of ADHD... Which of the following should the nurse include in the teaching?

History of head trauma

Introjection

Incorporation of values or qualities of an admired person or group into one's own ego

Passive-aggression

Indirectly expressing aggression toward others; a facade of overt compliance masks covert resentment

The clinic nurse notes bruises in various stages of healing... What questions must the nurse include?

Is anyone hurting you? When you and your spouse disagree, what happens to you? Has your spouse ever threatened you verbally or with violence?

... teaching a patient with a new prescription for naltrexone?

It helps prevent relapse by reducing your drug cravings

Clonidine (Opioid Withdrawal)

Lowers BP

... significant dental problems. The nurse expects that this patient abuses which substance?

METHAMPHETAMINES

Alcohol intoxication & Diabetic

Monitor blood glucose levels at night because of HYPOGLYCEMIA

Which of the following manifestations ... are indications of autism spectrum disorder? Select all that apply.

Nonverbal behavior Repetitive counting Spins a toy repetitively Delayed language development Exhibits ritualistic behavior

Rationalization

Offering an acceptable, logical explanation to make unacceptable feelings and behavior acceptable

A 79-year old ... weighs 93 lbs, and is wearing old, dirty clothes ... diagnosed with pneumonia. Which comment by this patient suggests a significant risk for abuse?

Our family is poor, so my daughter gets my monthly retirement and Social Security checks

The inability to leave one's home because of severe anxiety

Panic attacks with agoraphobia (Fear of leaving a safe place "riding on trains or buses")

MAOI

Phenelzine and Isocarboxzid

What is the most important intervention when admitting a child with autism spectrum disorder?

Placement in a private room down the corridor from the nurses' station

Naltrexone

Prevents relapse by reducing cravings

The client is agitated and fights against the nurse ... positive for cocaine... priority intervention?

Provide a calm atmosphere and monitor respiratory and cardiac status

9 year old hospitalized client on bedrest who has attention deficit disorder... Which of the following should the nurse prioritize?

Provide the child with a daily schedule that is typed or written

... injuries associated with intimate partner violence. The patient plans to return home. Which action by the nurse has priority?

Provide the patient with contact information for the local shelter.

A nurse is learning how to manage patients with substance abuse disorders. Which step should the nurse apply as a first-line intervention in such cases?

Providing safety and sleep

Q2: Child with autism spectrum disorder. Which statements by the parents indicate ... that they understand the teaching? Select all that apply.

Repetitive movements are common Non-verbal communication is limited Maintain a daily routine whenever possible

Which vital sign would be most concerning to the nurse?

Respirations 10 breaths/min

Regression

Reverting to an earlier level of development when anxious or highly stressed

A nursing diagnosis that should be considered for a child with attention deficit hyperactivity disorder is

Risk for injury

Client states... "every time I need to leave the house for work ... Mom becomes extremely anxious and cries that something terrible is going to happen to me." ... supports which psychiatric diagnosis?

Separation anxiety disorder

Isolation

Separation of an unacceptable feeling, idea, or impulse from one's thought process

SSRI

Sertraline & Paroxetine

... a patient tells the nurse, "I feel like I am going to die." Based on the statement the patient made, what level of anxiety is the patient experiencing?

Severe

Sublimation

Substitution of an unacceptable feeling with a more socially acceptable one

"I travel only by train because I am terrified of flying." ... phobic client is most likely to respond to which intervention?

Systematic desensitization

The client reports drinking socially ... states, "I am anxious and shaking inside." ... vital signs are Temp. 100 F (38 C), HR 120 bpm, RR 24/min, BP 130/90 mm Hg. Which conclusion does the nurse make?

The client has early signs of alcohol withdrawal

...clinical manifestations ... expected in a client with severe anxiety?

The client is pacing the hallway and tells the nurse he has a feeling of impending doom

Suppression

The intentional exclusion of feelings and ideas

Repression

The involuntary exclusion of a painful thought ot memory from awareness

Displacement

The transference of feelings to another person or object

Why must you maintain a patent airway with an unconscious post-ECT client?

They may vomit and it can lead to aspiration.

Denial

Unconscious failure to acknowledge an event, thought or feeling that is too painful for conscious awareness

Intellectualization

Using reason to avoid emotional conflicts

When do you expect the abuse to worsen?

When the victim moves toward independence from the abuser

Nursing care after ECT

a. Maintain patent airway b. check vitals q15 mins c. reorient the client after ECT (mild confusion is likely upon awakening, and short-term memory impairment may occur, as is usual with any anesthetic d. The client may or may not complain after ECT. However, common complaints that often occur after anesthesia is administered may include: 1. Modest headache 2. Mild muscle soreness 3. Moderate nausea 4. Retrograde amnesia

Nursing care before ECT

a. prepare client by teaching what the treatment involves b. avoid using the word "shock" when discussing the treatment with client and family. c. An anticholinergic (atropine sulfate) is usually given 30 minutes before treatment to dry oral secretions. d. A quick-acting muscle relaxant (succinylcholine) or a general anesthetic agent is given to the client before the ECT. This helps to relax the client thus preventing bone/muscle damage. e. Provide an emergency cart, suction equipment, and oxygen available in the room.

...client who abuses alcohol & illicit drugs... spouse tells the nurse: "have lied to his boss, his children, and his friends and I just don't think I can do this anymore." Which of the following best describes this behavior?

enabling

Methadone

low dose opioid (wean off addiction)

... result of sudden withdrawal from barbiturate use?

seizures

... new client ... spontaneous onset of hyperventilation, trembling, and an inability to concentrate. What is the nurse's priority action?

stay with the new client

Patient with chronic pain... A regular dose of analgesic medication is ineffective in reducing the patient's pain?

the patient is showing signs of tolerance

... classroom strategies for children who have ADHD. Which of the following information should the nurse plan to discuss with the teachers? Select all that apply.

● Allow for regular breaks ● Combine verbal instruction with visual cues ● Establish consistent classroom rules ● Decrease the amount of homework assigned

Which of the following are physiological signs of anxiety? Select all that apply

● Increased pulse rate ● Hyperglycemia ● Dilated pupils ● Dilated bronchioles ● Peripheral vasoconstriction

6 year old client with ... ADHD. What techniques should the nurse use to communicate most effectively with the client when asking the client to complete a task? Select all that apply.

● Obtain eye contact before speaking ● Use simple language ● Have him repeat what was said ● Praise him if he completes a task

a client with a severe level of anxiety is rocking back and forth ... stating, "Something bad is going to happen." Which action should the nurse take?

� Sit in a chair next the client's bed

Client ... becoming increasingly anxious. What initial actions should the nurse take for this client? Select all that apply.

� Stay by the client's side � Escort the client to a quiet place � Use a comforting tone of voice when speaking to the client

A patient who has to undergo surgery ... complains of chest pain, feelings of choking, and hot flashes. What appropriate diagnosis does the nurse make from the patient's symptoms?

� The patient has panic disorder