HESI RN
Mental Health HESI Questions
Question 1 of 5
A male client with a long history of alcohol dependency arrives in the emergency department describing the feeling of bugs crawling on his body. His BP is 170/102, pulse rate is 110 bpm, and his blood alcohol level (BAL) is 0 mg/dl. Which medication should the nurse administer?
Correct Answer: D
Rationale: In this scenario, the client is experiencing hallucinations and symptoms of alcohol withdrawal. Lorazepam (Ativan) is the appropriate choice as it helps manage withdrawal symptoms, including hallucinations and elevated blood pressure in alcohol-dependent clients. Haloperidol (Haldol) (Choice A) is an antipsychotic but is not the first-line treatment for alcohol withdrawal symptoms. Thiamine (Vitamin B1) (Choice B) is essential in alcohol withdrawal treatment for preventing Wernicke's encephalopathy, but in this case, addressing the acute withdrawal symptoms is the priority. Diphenhydramine (Benadryl) (Choice C) is an antihistamine that may help with itching or mild anxiety but is not the preferred choice for managing alcohol withdrawal symptoms like hallucinations and elevated blood pressure.
Question 2 of 5
A female client on a psychiatric unit is sweating profusely while vigorously doing push-ups and then running the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbance, the client shouts, "I am the boss here. I do what I want." Which nursing problem best supports these observations?
Correct Answer: D
Rationale: The client's behavior of engaging in disruptive and aggressive actions, as well as claiming authority over others in the setting, indicates a risk for other-directed violence. This behavior poses a potential threat to the safety of others in the environment. Choice A is incorrect as the client's behavior is not solely indicative of a lack of diversional activities but rather a more serious issue. Choice B is incorrect as the behavior described does not primarily reflect disturbances in personal identity but rather displays of power and aggression. Choice C is incorrect as the client's actions do not suggest an intolerance to activity but rather an excessive and potentially harmful level of hyperactivity.
Question 3 of 5
When preparing to administer a prescribed medication to a homeless male at a community psychiatric clinic, the client tells the nurse that he usually takes a different dosage. What action should the nurse take?
Correct Answer: B
Rationale: In this scenario, the correct action for the nurse to take is option B: withhold the medication until the dosage can be confirmed. This choice prioritizes patient safety by ensuring that the client receives the correct dosage of the prescribed medication, avoiding potential harm or adverse effects from an incorrect dosage. Option A is incorrect because administering a medication without verifying the dosage could lead to serious consequences for the client's health. Option C is also incorrect as it does not address the immediate need to confirm the correct dosage before administering the medication. Option D is not the best choice as it assumes the client is aware of the dosage change, which may not be the case. From an educational standpoint, this question highlights the importance of thorough medication administration practices in mental health nursing. Nurses must prioritize patient safety by verifying medication dosages before administration, especially when discrepancies or uncertainties arise. This situation also emphasizes the significance of clear communication with clients to ensure their understanding of prescribed treatments.
Question 4 of 5
The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. What information should the nurse explore in-depth with the client based on this screening tool?
Correct Answer: C
Rationale: In mental health nursing, the CAGE questionnaire is a commonly used screening tool to assess alcohol use disorder. Option C is the correct answer because it delves into crucial aspects of the client's behavior related to alcohol use. "Efforts to cut down" and "annoyance with questions" indicate resistance or denial, common defense mechanisms in substance use. "Guilt" is a common emotion associated with alcohol misuse. "Drinking as an eye-opener" suggests using alcohol to cope or self-medicate, which is significant in understanding the client's relationship with alcohol. Options A, B, and D are incorrect because they do not address the key components of the CAGE questionnaire. Cancer screening results, gastritis, liver enzymes, and bleeding are not directly related to alcohol use disorder screening. Missing family events or minimizing drinking alone do not provide insight into the client's perception of their drinking behavior or its impact on their life, as highlighted in option C. Educationally, understanding the rationale behind using specific screening tools like the CAGE questionnaire equips nurses with the skills to assess and intervene effectively in cases of alcohol use disorder. By exploring the nuances of the client's responses, nurses can tailor interventions and support to address underlying issues related to alcohol misuse.
Question 5 of 5
The nurse is planning client teaching for a 35-year-old client with early alcoholic cirrhosis. Which self-care measure should the nurse emphasize for the client's recovery?
Correct Answer: D
Rationale: Alcohol abstinence is the most critical self-care measure for a client with early alcoholic cirrhosis. Continued alcohol consumption can lead to further liver damage and worsen the condition. Support group meetings may offer emotional support but do not address the root cause of the issue. While vitamin supplements and a nutritious diet are important for overall health, alcohol abstinence takes precedence in managing cirrhosis caused by alcohol consumption.