HESI RN
Quizlet HESI Mental Health Questions
Question 1 of 5
Narcan was administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate (Vicodin). Within 15 minutes, the client is alert and oriented. In planning nursing care, which intervention has the highest priority at this time?
Correct Answer: C
Rationale: Observing the client for further narcotic effects is the priority at this time. It is crucial to monitor the client closely to prevent a relapse of symptoms or potential complications from the overdose. Encouraging fluid intake, obtaining serum Vicodin levels, and determining the reason for the suicide attempt are important but are secondary to ensuring the client's immediate safety and well-being by observing for any lingering effects of the narcotic.
Question 2 of 5
A female client engages in repeated checks of door and window locks, a behavior that prevents her from arriving on time and interferes with her ability to function effectively. What action should the nurse take?
Correct Answer: D
Rationale: Planning a list of daily activities can help the client manage her time better and reduce the impact of her compulsive behaviors. Option A is incorrect because simply asking why the client checks the locks may not address the underlying issue effectively. Option B is not relevant to the compulsive behavior of checking locks. Option C does not directly address the client's compulsive behavior but focuses on the physical attributes of the locks.
Question 3 of 5
A male client comes to the emergency center with an erection that will not resolve. The client reports that he is taking trazodone (Desyrel) for insomnia. Which information is most important for the nurse to ask this client?
Correct Answer: B
Rationale: In this scenario, the most important question for the nurse to ask the client is whether he is experiencing any other sexual dysfunctions or problems. This inquiry is crucial as it can help in determining if the persistent erection is a side effect of trazodone. Asking about medication for erectile dysfunction (Choice A) may not provide relevant information in this case, as the focus is on the potential side effects of trazodone. Inquiring about the last time the client consumed alcohol (Choice C) is not directly related to the situation at hand. Questioning about a history of angina or high blood pressure (Choice D) is important for overall assessment but is not as directly relevant to the immediate concern of the persistent erection potentially caused by trazodone.
Question 4 of 5
A female client with obsessive-compulsive personality disorder is admitted to the hospital for a cardiac catheterization. The afternoon before the procedure, the client begins to keep detailed notes of the nursing care she is receiving and reports her findings to the RN at bedtime. What action should the nurse implement?
Correct Answer: B
Rationale: Asking the client to explain why she is keeping a detailed record of her nursing care is the most appropriate action for the nurse to take in this situation. Understanding the client's motivations for keeping detailed records can provide insight into her obsessive-compulsive behaviors and help manage them effectively. Choice A is incorrect because it may come across as confrontational and not address the underlying reasons for the behavior. Choice C is incorrect as teaching strategies to control behavior should be done after understanding the client's motives. Choice D is incorrect as it does not directly address the behavior of keeping detailed records.
Question 5 of 5
A male client approaches the RN with an angry expression on his face and raises his voice, saying, "My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out!" The RN recognizes that the client is using which defense mechanism?
Correct Answer: B
Rationale: The correct answer is B: Projection. Projection involves attributing one's own unacceptable feelings or thoughts to others, as seen in the client's accusations of his roommate's behavior. In this scenario, the client is projecting his own anger and potential for violence onto his roommate. Choice A, Denial, involves refusing to acknowledge some aspect of reality. Choice C, Rationalization, is a defense mechanism where logical reasons are given to justify behaviors that are actually based on unacceptable motives. Choice D, Splitting, is a defense mechanism where a person sees others as all good or all bad, not applicable in this case.