RN HESI Mental Health 2023

Extract:

Question 1 of 5

Following involvement in a motor vehicle collision, a middle-aged adult client is admitted to the hospital with multiple facial fractures. The client's blood alcohol level is high on admission. Which PRN prescription should be administered if the client begins to exhibit signs and symptoms of delirium tremens (DTs)?

Correct Answer: C

Rationale: Lorazepam is a benzodiazepine used to manage delirium tremens (DTs), a severe form of alcohol withdrawal, by reducing agitation and preventing seizures. Prochlorperazine and chlorpromazine are antipsychotics, not first-line for DTs. Hydromorphone is an opioid and inappropriate for DTs management.

Question 2 of 5

Which intervention(s) should the nurse include in the plan of care for an adolescent client who is depressed? Select all that apply.

A. Restrict visitors to family members only B. Reinforce statements regarding a will to live and realistic plans for the future C. Discuss the client's suicide plan D. Encourage the client to discuss thoughts and feelings E. Limit time allowed to play video games

Correct Answer: B,C,D

Rationale: B: Reinforcing statements about a will to live provides hope. C: Discussing a suicide plan assesses risk and ensures safety. D: Encouraging discussion of thoughts and feelings promotes therapeutic communication. A: Restricting visitors may increase isolation. E: Limiting video games is less relevant to immediate depression management.

Question 3 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 4 of 5

Which individual should the nurse consider at highest risk for suicide?

A. A retired older male whose significant other has passed away B. A nurse who works in a pediatric emergency department C. An adolescent male whose parents recently divorced D. A single working mother with three pre-school aged children

Correct Answer: C

Rationale: Adolescents experiencing significant life changes like parental divorce are at increased suicide risk due to emotional upheaval and limited coping skills. Older males may have coping mechanisms. Stressful jobs or parenting are less specific risk factors without additional context.

Question 5 of 5

The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?

A. Alert the assigned staff to closely monitor client and intervene as needed to reduce risk of self-mutilation B. Provide the client time alone in the client's room to reduce external stimulation and promote relaxation C. Give the client firm, consistent expectations that self-mutilating behaviors are unacceptable and will not be allowed D. Complete a thorough room search to ensure the client does not have access to objects that can be used for self-harm

Correct Answer: A

Rationale: Alerting staff to monitor the client closely addresses the immediate risk of self-harm indicated by increased tension and pacing. Time alone may increase risk. Setting expectations is important but not immediate. Room searches are preventive but not the priority during acute distress.

RN HESI Mental Health 2023 | Nurselytic

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