(N125) HESI Practice

A delirious client sees a design on the wallpaper and perceives it as an animal. How should a nurse communicate in the change-of-shift report what the client perceived? 1. A delusion 2. An illusion 3. A hallucination 4. An idea of reference

2 Rationale: An illusion is a misperception or misinterpretation of an actual external stimulus. A delusion is a false belief that cannot be changed even by evidence; it is associated with psychosis. A hallucination results from an imaginary, not real, stimulus. An idea of reference is a belief that others are talking about the person.

A hospitalized client hurriedly approaches the nurse, saying that it sounds like there is a roaring fire in the bathroom. In reality, the client's roommate has just turned the shower on full force. What term best describes this experience? 1. Illusion 2. Delusion 3. Dissociation 4. Hallucination

1 Rationale: An illusion is a misperception of an actual stimulus. A delusion is a fixed false belief that is unrelated to an external stimulus. Dissociation is a disturbance in the integrative functions of the client. A hallucination is a false perception with no actual external stimulus.

A nurse is caring for an angry, hostile client with the diagnosis of borderline personality disorder. What is probably an issue for this client? 1. Low self-esteem 2. Inability to test reality 3. Disturbed energy field 4. Ineffective verbal communication

1 Rationale: The client is demonstrating a reaction to low self-esteem with hostile behavior. People with borderline personality disorder often have identity disturbances. There is no evidence of an inability to test reality, a disturbed energy field, or impaired verbal communication.

A nurse who is assessing a recently hospitalized client with a diagnosis of opioid addiction should look for signs of withdrawal. What are these signs? Select all that apply. 1. Seizures 2. Yawning 3. Drowsiness 4. Constipation 5. Muscle aches

1, 2, 5 Rationale: Seizures, yawning, and muscle aches are all clinical manifestations of opioid withdrawal, which occurs after cessation or reduction of prolonged moderate or heavy use of opioids. Insomnia, not drowsiness occurs with opioid withdrawal. Diarrhea, not constipation, occurs with opioid withdrawal..

A nurse is working in a clinic that provides services to clients who abuse drugs. What effect of cocaine should the nurse consider as the reason that it easily causes dependence? 1. Eases pain 2. Blurs reality 3. Clears the sensorium 4. Decreases motor activity

2 Rationale: The addict tries to avoid stress and reality. The drug produces a blurring of these feelings to the point that the addict becomes dependent on it. The psychological effect is usually more important than the ability to ease pain. Large doses of opioids, not cocaine, can cause a dreamlike state. Cocaine can increase, not decrease, motor activity.

How should the nurse help a disturbed, acting-out child develop a trusting relationship? 1. Inquire about the child's feelings regarding the parents. 2. Implement a half-hour one-on-one interaction every day. 3. Initiate limit-setting and explain the rules to be followed. 4. Offer periodic support and emphasize safety in play activities.

4 Rationale: Offering periodic support and emphasizing safety in play activities sets a foundation for trust because it allows the child to see that the nurse cares. Inquiring about the child's feelings regarding the parents would be threatening at this stage of the relationship. Implementing a half-hour one-on-one interaction daily is too infrequent for the development of trust. Although initiating limit-setting and explaining the rules to be followed are necessary, limit-setting does not support the development of a trusting relationship as much as providing support and emphasizing safety do.

A hospitalized, depressed, suicidal client has been taking a mood-elevating medication for several weeks. The client's energy is returning, and the client no longer talks about suicide. What should the nurse do in response to this client's behavior? 1. Keep the client under close observation. 2. Arrange for the client to have more visitors. 3. Engage the client in preliminary discharge planning. 4. Observe the client for side effects of the medication.

1 Rationale: As the client's motivation and energy return, the likelihood that suicidal ideation will be acted out increases. There are no data regarding visitation rights; the priority concern is the greater risk for suicide. Although engaging the client in preliminary discharge planning eventually will be done, the priority is determining the potential for suicide. Although the client should be observed for side effects of the medication, the greater risk of suicide takes precedence.

What is the best nursing intervention to encourage a socially withdrawn client to talk? 1. Focusing on nonthreatening subjects 2. Trying to get the client to discuss feelings 3. Asking simple yes-or-no questions of the client 4. Sitting quietly while looking through magazines with the client

1 Rationale: Nursing care involves a steady attempt to draw the client into some response. This can best be accomplished by focusing on nonthreatening subjects that do not demand a specific response. The client is not ready yet to discuss feelings; the first step is to focus on nonthreatening subjects. Yes-or-no questions do not encourage communication. By sitting quietly with the client the nurse is showing acceptance of the client but doing nothing to encourage communication.

The nurse refers a client to a self-help group. What does the nurse anticipate that a self-help group such as Alcoholics Anonymous (AA) will help its members learn? 1. That their problems are not unique 2. That they do not need a crutch to lean on 3. That their problems are caused by alcohol 4. That the group can stop them from drinking

1 Rationale: Sharing problems with others who have similar problems can help one explore feelings and begin to enhance coping abilities. The Twelve Steps of AA guide alcoholics to seek help from a higher power, which may be religious, based in nature, or the group itself. Problem drinking usually is caused by how the drinker feels about himself or herself. Although AA is a support group, it is a self-help support group. The only one who can stop someone from drinking is the person who is drinking.

For what clinical manifestations should the nurse assess a client during the first few hours of the alcohol withdrawal? Select all that apply. 1. Irritability 2. Tachycardia 3. Hallucinations 4. Increasing anxiety 5. Profuse diaphoresis

1, 2, 4 Rationale; Alcohol is a central nervous system depressant; irritability and increasing anxiety reflect the body's neurologic adaptation to the withdrawal of alcohol. Tachycardia is one of the early sign of withdrawal; it results from autonomic overactivity. Hallucinations are not early signs of alcohol withdrawal; they usually do not occur before 48 to 72 hours of abstinence. Fever and diaphoresis are later signs of withdrawal that may be seen during alcohol withdrawal delirium; they result from autonomic overactivity.

A nurse is working with children who have been sexually abused by a family member. What overwhelming feelings do these children usually express? Select all that apply. 1. Guilt 2. Anger 3. Revenge 4. Disbelief 5. Self-blame

1, 2, 5 Rationale: Sexually abused children often have nonsexual needs met by their abuser and are powerless to refuse; ambivalence results in self-blame and guilt. Anger may exist, especially toward the nonabusive parent who is not protecting the child. Disbelief or a desire for revenge may exist, but neither is the overwhelming feeling reported.

A man with bipolar disorder, manic episode, has been traveling around the country, dating multiple women, and buying his dates expensive gifts. He is admitted to the hospital when he becomes exhausted and runs out of money. The nurse anticipates that during a manic episode the client is most likely experiencing feelings of what? 1. Guilt 2. Grandeur 3. Worthlessness 4. Self-deprecation

2 Rationale: During a manic episode a client has an inflated self-esteem that replaces feelings with which the client cannot cope. Feelings of guilt, worthlessness, and self-deprecation are not associated with bipolar disorder, manic episode.

An older resident in a nursing home who has a diagnosis of dementia hoards leftover food from the meal tray and other seemingly valueless articles and stuffs them into pockets "so the others won't steal them." What should the nurse plan to do? 1. remove the resident's unsafe and soiled articles during the night. 2. Give the resident a small bag in which to place selected personal articles and food. 3. Explain to the resident why the nursing home's policy for cleanliness and safety must be followed. 4. Explain to the resident that the staff is required to keep harmful objects out of reach in the resident's closet.

2 Rationale: Giving the resident a small bag in which to place selected personal articles and food allows the client to exercise the right to decide which articles to keep and helps ensure safety and cleanliness. Removing the resident's unsafe and soiled articles during the night deceives the client and will create mistrust toward the staff. Because of the client's decreased attention span and memory, explanations alone will not help ensure safety or meet this client's needs. Telling the resident that the staff is required to keep harmful objects out of reach in the resident's closet does not address the client's needs; no data indicate that the resident is hoarding harmful objects.

The nurse manager is observing the performance of a nursing assistant. Which behavior by the nursing assistant toward a client reflects a boundary violation? 1. Offering advice to the client 2. Providing false reassurance 3. Accepting a gift from the client 4. Engaging in excessive probing

3 Rationale: A boundary violation occurs when a provider of care goes beyond the established therapeutic relationship standard and enters into a personal or social relationship with a client, such as with accepting a gift from the client. Offering advice to the client is an example not of a boundary violation but rather of inadequate communication skills; advice should not be given because it undermines the client's ability to solve problems and may precipitate dependency and helplessness. False reassurance is an example not of a boundary violation but rather of inadequate communication skills; false reassurance should not be given because it is not based in reality and may close off communication. Engaging in excessive probing is an example not of a boundary violation but rather of inadequate communication skills; inappropriate probing is not therapeutic and may be done by the provider of care to prevent uncomfortable silences or obtain information because of curiosity.

During the termination phase of a therapeutic relationship a client misses a series of appointments without any explanation. What should the nurse do? 1. Terminate the relationship immediately. 2. Explore personal feelings with the supervisor. 3. Contact the client to encourage another session. 4. Plan to attend the remaining designated meetings.

3 Rationale: An additional meeting is important to address the client's problem in regard to termination or determine whether there is some other reason for the client's absence. Terminating the relationship immediately will not be therapeutic, because issues will not be resolved. The nurse may want to explore personal feelings with the supervisor; however, the focus should be on the needs of the client. The client may not attend the remaining designated meetings. The nurse must reach out to help the client with the termination process.

A client calls the emergency department of the hospital after taking 24 sleeping pills. Which statement best describes the psychodynamics of calling the emergency department during the very act of a suicide attempt? 1. A need for attention 2. A need to punish others 3. Ambivalence about dying 4. An inability to stick to a decision

3 Rationale: Calling for help during a suicide attempt demonstrates the client's unconscious will to live or to be stopped from dying; the contrasting feelings of wanting to die and yet wanting to live demonstrate ambivalence. Seeking help is not always an attention-getting device. This is a cry for help rather than an expression of anger or an attempt to punish anyone else. The client obviously had the intention of suicide, but the wish to live was apparently stronger than the wish to die.

A 20-year-old woman is brought to an emergency department after having been raped. She is very anxious and cannot recall any of the circumstances surrounding the assault or provide the police with a description of the rapist. What defense mechanism does the nurse know is being utilized by this woman? 1. Projection 2. Regression 3. Repression 4. Displacement

3 Rationale: Repression occurs when an individual unconsciously excludes distressing emotions, thoughts, or experiences from her awareness. It is a mechanism to help her deal with the shock of stressful emotional experiences. A repressed memory is "forgotten" and cannot be deliberately brought to awareness. Projection occurs when an individual attributes his or her own unacceptable feelings and thoughts to others, allowing the individual to blame others for personal shortcomings. Regression occurs when an individual reverts to an earlier stage of development involving less mature behavior and responsibility as a way of coping with a stressful situation; it often results in more dependent behavior. Displacement occurs when an individual releases pent-up feelings on people perceived to be less dangerous than those who initially aroused the emotion. For example, after receiving a speeding ticket from the police a man yells at his wife when she asks him how his day went.

A client with schizophrenia is demonstrating waxy flexibility. Which intervention is the best way to manage the possible outcome of this behavior? 1. Providing thickened liquids to minimize the risk of aspiration 2. Documenting intake and output each shift to monitor hydration 3. Reinforcing appropriate social boundaries through staff role modeling 4. Performing passive range-of-motion exercises three times a day for effective joint health

4 Rationale: Waxy flexibility is an excessive and extended maintenance of posture that can lead to a variety of problems, including joint trauma. Passive range-of-motion exercises focus on the effective management of joint mechanics. Although aspiration precautions, documentation of intake and output, and staff role modeling may address issues experienced by a client with schizophrenia, passive range-of-motion exercises address waxy flexibility.

A client is admitted to a mental health facility because of maladaptive coping behavior. How can the nurse best help the client develop healthier coping mechanisms? 1. By providing a stress-free environment 2. By promoting interpersonal relationships with peers 3. By allowing the client to assume responsibility for decisions 4. By setting realistic limits on the client's maladaptive behavior

4 Rationale; Setting realistic limits on the client's maladaptive behavior provides structure that promotes learning acceptable behavior. No environment is stress free. The client may not be ready for relationships with peers or responsibility for decisions at this time.

The personality characteristics of a client with an antisocial personality disorder make it difficult for family members to interact and maintain a healthy relationship. What are common characteristics of an antisocial personality? Select all that apply. 1. Aloof 2. Suspicious 3. Perfectionist 4. Irresponsible 5. Manipulative

4, 5 Rationale: People with antisocial personalities are often irresponsible, amoral, and dishonest and do not learn from negative experiences. People with antisocial personalities are often charming and calculating when exploiting others; they show no remorse for hurting others and do not develop insight into predictable consequences. Aloofness is associated with the schizoid personality. Suspiciousness is associated with the paranoid personality. Perfectionism is associated with the paranoid personality.

A recently hired nurse is caring for several clients on a mental health unit at a local community hospital. The nurse manager is evaluating the nurse's performance. What situation indicates that the nurse-client boundaries of the recently hired nurse are appropriate? 1. The nurse shares with the entire treatment team vital information the client disclosed in a private session. 2. The nurse is often busy doing other tasks when the client and nurse are scheduled for a counseling session. 3. A client enters the therapeutic group late with the nurse's permission even though group rules say that this is not allowed. 4. A client's overall behavior is significantly more independent and demonstrates higher function on the days that the nurse is not working.

1 Rationale: The nurse is part of the treatment team and must share vital information with its members. When the nurse is underinvolved in the nurse-client relationship, respect and trust, which are necessary for therapy, do not develop. The nurse must not place other responsibilities over the commitment made to the client. A nurse who becomes overinvolved in the nurse-client relationship may bend the rules for a specific client. This is detrimental to that client and other clients who see the preferential treatment. A nurse who becomes overinvolved in the nurse-client relationship may also foster regressive behaviors that make the client more dependent.

A nurse is assessing a client and attempting to distinguish between dementia and delirium. Which factors are unique to delirium? Select all that apply. 1. Slurred speech 2. Lability of mood 3. Long-term memory loss 4. Visual or tactile hallucinations 5. Insidious deterioration of cognition 6. A fluctuating level of consciousness

1, 4, 6 Rationale: Delirium, a transient cognitive disorder caused by global dysfunction in cerebral metabolism, results in sparse or rapid speech that may be slurred and incoherent. Visual or tactile hallucinations and illusions may occur with delirium because of altered cerebral function; hallucinations are not prominent with dementia. Clients with delirium fluctuate from hyperalert to difficult to arouse; they may lose orientation to time and place. Clients with dementia do not have a fluctuating level of consciousness, but they may be confused and disoriented. Clients with delirium are consistently irritable, anxious, and fearful; lability of mood is associated with dementia. Short-term memory loss is associated with both delirium and dementia; eventually long-term memory loss is associated with dementia. The onset of delirium is abrupt (hours to days) and has an organic basis; it is often precipitated by drugs such as anesthesia, analgesics, and antibiotics or by conditions such as infections, end-stage kidney disease, and substance abuse or withdrawal. The onset of dementia is slow and insidious (years).

When determining whether a client has anorexia nervosa or bulimia nervosa, the nurse should identify those characteristics that relate only to anorexia nervosa. Select all that apply. 1. Cachexia 2. Binge eating 3. Constipation 4.Intolerance of heat 5. Delayed psychosexual development

1, 5 Rationale; A state of malnutrition with muscle wasting, weakness, and emaciation (cachexia) occurs with anorexia nervosa; clients usually are 15% to 30% below ideal body weight. Many clients with anorexia nervosa exhibit psychological symptoms, including a lack of age-appropriate interest in sex and relationships. Recurrent episodes of the rapid consumption of a large amount of food in a discrete period (binge eating) are associated with bulimia nervosa. Constipation can occur with both anorexia nervosa and bulimia nervosa, usually because of a lack of adequate fluids and intestinally stimulating foods. Clients with anorexia nervosa or bulimia nervosa have intolerance of cold caused from a loss of body fat.

A nurse facilitating a support group of widows and widowers recalls that research indicates that the probability of a spouse having a pathological or morbid grief response will be greater in what case? 1. The couple had an ambivalent relationship. 2. The cause of the spouse's death was suicide. 3. The relationship between the spouses was satisfying. 4. There was a long preparatory grief period before a spouse's death.

2 Rationale: The survivors of a suicide feel more guilt and bitterness and go through a longer grieving process, and therefore the chances of a pathological grief response are increased. An ambivalent relationship between the spouses may result in a difficult grief response because of guilty feelings but should not cause a morbid grief response. Research documents that the more satisfying the relationship, the more likely that the mourner will establish a new relationship. With a preparatory grief period a person may have the opportunity to work through a part of the grief process before the death and have a shorter mourning period after the death.

A male client in a mental health facility turns his head to the side during a unit meeting as if he hears something. When the nurse comments about it, the client replies, "You know, it's that microcomputer those foreign agents implanted in my ear." In light of this statement, what does the nurse determine that the client is experiencing? 1. Illusions 2. Delusional thoughts 3. Neologistic thinking 4. Disorganized cognition

2 Rationale; The client's statement reveals the cognitive disturbance called a delusion, which is a fixed set of false beliefs that cannot be corrected by reason. An illusion is a misperception of an actual environmental stimulus. Disorganized thought would include the inability to organize thought process. Neologisms are made-up words understood only by the speaker.

.When a recently hospitalized client has a tentative diagnosis of opioid addiction, the nurse should assess the client for signs and symptoms related to opioid withdrawal. List them in the order that they will occur as the client progresses through withdrawal. 1. Muscle twitching 2. Runny nose and irritability 3. Return of appetite 4. Flulike syndromes

2, 1, 4, 3 Rationale: When opioids, which are central nervous system depressants, are withdrawn initially, the client will experience a runny nose (rhinorrhea), tearing (lacrimation), diaphoresis, yawning, and irritability. As withdrawal progresses, rebound hyperexcitability precipitates muscle twitching, restlessness, hypertension, tachycardia, temperature irregularities, tremors, and loss of appetite. Finally flulike symptoms, insomnia, and yawning occur. Once withdrawal is complete the appetite returns, vital signs become stable, and other withdrawal signs and symptoms subside and eventually disappear.

A client who is a polysubstance abuser has been ordered by the court to seek drug and alcohol counseling. When working with the client, the nurse identifies several treatment goals. List in priority order the outcome criteria for this client. 1. Discusses effect of drug use on self and others 2. Verbalizes that a substance abuse problem exists 3. Explore the use of substances and problematic behaviors 4. Expresses negative feelings about the current life situation

2, 1, 4, 3 The client must first acknowledge that a substance abuse problem exists and creates chaos in his life. The client can then discuss the numerous ways in which drug use has changed and controlled his life. Assistance from the nurse may be required at this time for the client to express and process negative feelings. Finally the client will require assistance in establishing the relationship between substance use and his current problems.

The son of a terminally ill woman is concerned about his mother's condition. He asks the nurse, "Will she get better?" What is the most appropriate response by the nurse? 1. "Her vital signs are stable. Right now she's holding her own." 2. "Of course she will. You can't give up. You have to hope for the best." 3. "Her condition is very serious. It might help you if we discuss your concerns." 4. "I don't know; you'll have to ask her oncologist. I'll leave a note that you're here."

3 Rationale: Offering to discuss the situation provides the son with an opportunity to express his feelings. Telling the son that the woman is holding her own does not address the family member's concern. Telling the son that the woman will pull through is false reassurance and cuts off communication. Telling the son to speak with the health care provider shuts off communication and abdicates nursing responsibility to the client.

What is the nurse's specific responsibility when the rights of a client on a mental health unit are restricted by the use of seclusion? 1. Informing the client's family 2. Monitoring pharmacologic interventions 3. Completing a denial-of-rights form and forwarding it to the administrative officer 4. Documenting both the client's behavior and the reason that specific rights were denied

4 Rationale: Seclusion and restraints are special procedures for dealing with aggressive acting-out behavior for the protection of the client and others; clear documentation is essential when the client's rights are restricted. Informing the client's family is not necessary because the use of seclusion or restraints is included in the general consent form that is signed on admission. Pharmacologic intervention should be monitored for all clients. There is not a typical form; however, documentation is required to justify the need for seclusion or the use of restraints.

A staff member tells a nurse that an older client becomes irritable when asked to assist with activities of daily living. On what general information about older adults should the nurse base a response? 1. Decreased ability to cope 2. Loss of ability to cooperate 3. Ambivalence toward authority 4. Difficulty performing step procedures

1 Rationale: Fears and anxieties about themselves and their possessions are common in older adults because of a decreased self-concept and an altered body image; these changes result in a decreased ability to cope. Aging need not necessarily bring about a loss of one's ability to cooperate. The attitude of older adults concerning authority or others in their environment is set; indecision about life situations may be a result of insecurity. Difficulty performing step procedures is noted in the middle stage of Alzheimer disease; usually it is not observed in older adults.

After caring for a terminally ill client for several weeks, a nurse becomes increasingly aware of a need for a respite from this assignment. What is the best initial action by the nurse? 1. Requesting a few days' vacation time 2. Seeking support from colleagues on the unit 3. Withdrawing emotional involvement with the client 4. Staying with the client while trying to work through the feelings

2 Rationale: Talking with colleagues who face or who have faced the same problems may provide constructive help with the situation. Requesting vacation time is an avoidance technique; these feelings must be addressed. Withdrawing emotional involvement with the client does not address the needs of the nurse and may interfere with a productive nurse-client relationship. Staying with the client while trying to work through the feelings does not address the needs of the nurse and may interfere with a productive nurse-client relationship.

A client with the diagnosis of borderline personality disorder has been exhibiting manipulative, inappropriate behavior and consistently attempting to take advantage of the other clients. What should the nurse consider first before confronting the client? 1. The last time medication was given 2. The depth of their working relationship 3. The client's ability to be empathic toward others 4. The degree of self-awareness exhibited by the client

2 Rationale: The establishment of trust between the client and nurse should be a prerequisite for the use of confrontation. The last time medication was administered is not a significant factor in relation to the use of confrontation. Clients with the diagnosis of borderline personality disorder tend to be impulsive and egocentric and have difficulty being empathic toward others. Client self-awareness is not a prerequisite for the use of confrontation; the purpose of confrontation is to help the client become self-aware.

The nurse is caring for a client who has attempted suicide. What is the most desirable short-term client outcome during this crisis situation? 1. Strengthening coping skills 2. Establishing a no-suicide contract 3. Learning problem-solving techniques 4. Recognizing why suicide was attempted

2 Rationale: The primary goal is to keep the client safe. A no-suicide contract secures the client's agreement not to attempt suicide for a specified period and to seek help when suicidal ideas occur. Improving the client's coping skills is part of the treatment plan after the immediate crisis has been controlled. Teaching problem-solving is part of the long-range treatment plan after the immediate crisis is controlled.

A client tells the nurse, "I'm a terrible, evil person. The voices are telling me that God needs to punish me." What is the most therapeutic initial response by the nurse? 1. "God is loving and won't punish you." 2. "Those voices you're hearing are a fantasy." 3. "Tell me what you're thinking about yourself." 4. "You aren't wicked—both God and I love you."

3 Rationale: Encouraging the client to focus on the self will facilitate communication and foster self-perception. Stating that God will not punish the client denies the client's feelings and provides false reassurance. Stating that the voices are fantasy denies the client's experience. Stating that the client is not wicked denies the client's feelings and provides false reassurance.

A nurse is caring for a client with antisocial personality disorder. What client characteristic should the nurse consider when formulating a plan of care? 1. Suffers from extreme anxiety 2. Rapidly learns by experience if punished 3. Usually is unable to postpone gratification 4. Has a great sense of responsibility toward others

3 Rationale: Individuals with antisocial personality disorder tend to be self-centered and impulsive. They lack judgment and self-control and are unable to postpone gratification. Generally they do not suffer from anxiety. These individuals believe that the rules do not apply to them, and they do not profit from their mistakes. These people are too self-centered to have a sense of responsibility to anyone.

A nurse is orienting a new client to the unit when another client rushes down the hallway and asks the nurse to sit down to talk. The client requesting the nurse's attention is manipulative and uses acting-out behaviors when demands go unmet. How should the nurse intervene? 1. By suggesting that the client requesting attention speak with another staff member 2. By leaving the new client, saying, "I'll talk with the other client until things calm down." 3. By introducing the two clients and suggesting that the client join them on a tour of the facility 4. By saying to the interrupting client, "I'll be back to talk with you after I orient this new client."

4 Rationale: "I'll be back to talk with you after I orient this new client" sets realistic limits on behavior without rejecting the client. Suggesting that the client requesting attention speak with another staff member will constitute a rejection of the client rather than the behavior. Leaving the new client, saying, "I'll talk with the other client until things calm down," will encourage further manipulation by the client. The other client is entitled to dedicated time with the nurse; asking the interrupting client to join them is inconsistent limit-setting on the part of the nurse.