RN HESI Mental Health 2023

Extract:

Question 1 of 5

A client with schizophrenia returns to the clinic two weeks after receiving a prescription for haloperidol. To assess for neuroleptic malignant syndrome (NMS), which information is most important for the nurse to obtain during this visit?

Correct Answer: A

Rationale: Current vital signs are critical for assessing NMS, a life-threatening side effect of haloperidol, indicated by fever, unstable blood pressure, and tachycardia. White blood cell count, urinary output, and blood sugar are less specific to NMS.

Question 2 of 5

When the nurse addresses questions to an adult client who is depressed, the client's responses are delayed. Which intervention should the nurse include in the client's plan of care?

A. Involve client in daily exercise program B. Ask the client to describe her depression C. Spend time sitting in silence with client D. Observe for signs of possible psychosis

Correct Answer: C

Rationale: Spending time sitting in silence with the client provides a supportive presence without pressure for immediate responses, which is helpful for depression-related delays in communication. Exercise may be beneficial but does not address delayed responses directly. Asking about depression is useful for assessment but not immediate needs. Observing for psychosis is not indicated unless other symptoms are present.

Question 3 of 5

A client engages in repeated checks of door and window locks and behavior that prevents the client from arriving on time and interfering with the ability to function effectively. Which action should the nurse take?

A. Determine the type and size of the locks B. Plan a list of activities to be carried out daily C. Discuss checking the time frequently D. Ask the client why the locks are checked so frequently

Correct Answer: B

Rationale: Planning a list of daily activities helps establish a structured routine, reducing time spent on compulsive checking and promoting effective functioning. Determining lock types is irrelevant. Discussing time-checking does not address lock-checking. Asking 'why' may increase frustration, as compulsive behaviors are anxiety-driven.

Question 4 of 5

Mark which behaviors might be related to alcohol intoxication, acute phase of rape-trauma syndrome, or both. Tick only 1 box.

A. Numbness: Rape-trauma syndrome B. Poor decision making: Alcohol intoxication C. Crying: Both D. Disbelief: Rape-trauma syndrome E. Irritability: Alcohol intoxication F. Difficulty concentrating: Both

Correct Answer: C

Rationale: Crying occurs in both alcohol intoxication (due to disinhibition) and rape-trauma syndrome (due to emotional distress). Numbness and disbelief are specific to rape-trauma syndrome. Poor decision making, irritability, and difficulty concentrating are typical of alcohol intoxication, though the latter can also occur in rape-trauma syndrome.

Question 5 of 5

A client who is an alcoholic receives a prescription for disulfiram 500 mg by mouth (PO) daily. Which instruction should the nurse provide to this client?

A. Take the medication at bedtime and avoid consuming any more than one ounce of alcohol B. Take the medication with at least 8 ounces (240 mL) of water and limit alcohol consumption while taking this medication C. Begin taking the medication immediately and take it daily, regardless of whether or not you drink alcohol D. Take the medication each morning beginning 48 hours after your last drink of alcohol

Correct Answer: D

Rationale: Disulfiram must be started at least 48 hours after the last alcohol intake to prevent severe reactions, and alcohol must be completely avoided. Options A and B incorrectly suggest limited alcohol is safe. Option C risks reactions if alcohol is still in the system.