Quizlet Mental Health HESI - Nurselytic

Correct Answer: B

Rationale: The correct answer is B because clients with depression or psychosis may interpret TV as sending messages, so it is often removed to prevent this risk.
Choice A is incorrect because it does not address the client's concern and may not be feasible.
Choice C is incorrect because it diverts from the client's immediate issue regarding the TV.
Choice D is incorrect because it does not address the client's specific concern and instead focuses on the activity level.

Correct Answer: A

Rationale: Asking about the amount of sleep a woman gets each night is crucial in understanding her circadian rhythms and how they may affect her quality of life. Circadian rhythms are the body's internal clock that regulates the sleep-wake cycle. Monitoring sleep patterns can provide insights into how well these rhythms are functioning and impacting daily life.

Choices B, C, and D are unrelated to circadian rhythms and do not directly assess the effects of these rhythms on quality of life.

Correct Answer: D

Rationale: When dealing with a client experiencing auditory hallucinations, it is crucial for the nurse to first listen to what the client is saying. Auditory hallucinations may hold significance to the client, and by actively listening, the nurse can gather information about the content and context of the hallucinations. This information helps the nurse assess the client's current state, emotional responses, and the potential triggers for the behavior. Administering a PRN sedative (
Choice
A) should not be the initial action as it may suppress important information and feelings the client is trying to communicate. Sitting next to the client (
Choice
B) may not be appropriate without understanding the situation better. Escorting the client to his room (
Choice
C) may escalate the situation without addressing the underlying cause of the behavior, which can be better understood through active listening.

Correct Answer: A

Rationale: When a nurse observes a discrepancy between a client's verbal and nonverbal communication, it is essential to pay close attention and document the nonverbal messages. Nonverbal cues, such as body language and facial expressions, can provide valuable insights into the client's emotional state, feelings, and concerns that may not be expressed verbally. By documenting these nonverbal messages, the nurse can gain a more comprehensive understanding of the client's communication and address any potential underlying issues. Asking the client's husband to interpret the discrepancy (
Choice
B) may not always provide an accurate understanding of the client's nonverbal cues. Ignoring the nonverbal behavior (
Choice
C) could lead to missing important cues affecting the client's care. Integrating verbal and nonverbal messages (
Choice
D) is important, but initially focusing on documenting and understanding the nonverbal cues can enhance the nurse's assessment and communication with the client.

Correct Answer: B

Rationale: The correct action for the charge nurse is to advise the client that assignments are not based on client requests. Clients with antisocial personality disorder may attempt to manipulate situations to their advantage. By setting clear boundaries and explaining that assignments are not based on client preferences, the nurse helps prevent manipulation and maintains a professional approach to care. Reassuring the client about his requests (
Choice
A) may encourage the inappropriate behavior to continue. Asking the client to explain his requests (
Choice
C) may further fuel the manipulation by providing an opportunity for the client to justify his actions. Encouraging the client to verbalize feelings (
Choice
D) does not address the underlying issue of manipulating the assignment process and may inadvertently reinforce the behavior.