RN Hesi Mental Health

Extract:

History and Physical
Nurse's Notes
Orders
The client is in the hospital after her house collapsed during a hurricane. She has been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue monitoring her respiratory function and to complete intravenous antibiotic administration.

Question 1 of 5

For each client statement, click to highlight the statement(s) below that require follow-up teaching by the nurse.

Correct Answer: A,C,D,F

Rationale: Statements about being 'crazy,' typical stress responses, holistic approaches, and lifelong medication need clarification to address stigma, variability in trauma responses, and treatment plans.

Extract:

Question 2 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. Complete a thorough room search to ensure the client does not have access to objects that can be used for self-harm. B. Provide the client time alone in the client's room to reduce external stimulation and promote relaxation. C. Alert the assigned staff to closely monitor the client and intervene as needed to reduce the risk of self-mutilation. D. Give the client firm, consistent expectations that self-mutilating behaviors are unacceptable and will not be allowed.

Correct Answer: C

Rationale: Close monitoring and intervention are critical to prevent self-harm in a client showing signs of distress, prioritizing safety.

Question 3 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. Which information should the nurse explore in-depth with the client based on this screening tool?

A. Cancer screening results, anger, gastritis, daily alcohol intake. B. Consumption, liver enzyme, gastrointestinal complaints, and bleeding. C. Efforts to cut down, annoyance with questions, guilt, and drinking as an 'Eye-opener.' D. Minimizes drinking, frequently misses family events, guilt about drinking, and amount of daily intake.

Correct Answer: C

Rationale: The CAGE questionnaire assesses alcohol dependency through efforts to cut down, annoyance, guilt, and eye-opener drinking, which should be explored in-depth.

Question 4 of 5

The nurse is developing a plan of care for an older client with hypertension who reports chest pain on exertion. Which outcome should the nurse include in the plan of care for this client?

A. The nurse will call the client weekly to monitor the client's blood pressure and symptoms. B. The nurse will encourage the client to walk thirty minutes every day. C. The client will take up to 4 nitroglycerine tablets sublingually for chest pain. D. The client will record episodes of angina and self-management for one week.

Correct Answer: D

Rationale: Recording episodes of angina and self-management for one week is a specific and appropriate outcome to monitor the client's chest pain and response to interventions. Weekly monitoring, daily walking, and nitroglycerine use are important but do not directly address tracking angina episodes for management.

Question 5 of 5

An adolescent client is admitted to the postoperative unit following open reduction of a fractured femur which occurred when the client fell down the stairs at a party. The nurse notices needle marks on the client's arms. Which assessment findings should the nurse document related to suspected narcotic withdrawal?

A. Vomiting, seizures, and loss of consciousness. B. Agitation, sweating, and abdominal cramps. C. Depression, fatigue, and dizziness. D. Hypotension, shallow respirations, and dilated pupils.

Correct Answer: B

Rationale: Agitation, sweating, and abdominal cramps are indicative of narcotic withdrawal, consistent with opioid use suggested by needle marks.

RN Hesi Mental Health | Nurselytic

Nurselytic

HESI RN

HESI RN