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Questions 37

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RN Hesi Mental Health Questions

Extract:

History and Physical
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. Nurses' Notes
0900
Pain assessment completed. The client's pain is 2/10. The client requests sleeping medication for the night. She states that she has horrible thoughts and memories about the house collapsing all the time and that it is keeping her from falling asleep. She states, "I used to be so happy before all of this happened. Now I can't seem to get out of this funk I am in." The client would also prefer to be in a quieter area of the unit as she is currently by the nurses' station and hears talking and alarms constantly.


Question 1 of 5

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. The nurse engages the client in conversation about her feelings and some of her coping mechanisms. Click to specify which client statement or behavior is most likely associated with each of the listed defense mechanisms.

Correct Answer: A,B,C,D

Rationale: Fantasy (Hawaii move) escapes reality, isolation (unemotional) separates emotions, suppression (forgetting hospitalization) avoids distress, and denial (hospital fire fear) projects trauma.

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 2 of 5

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

This diagnosis means that I am crazy.'
I can learn to manage my thoughts better through therapy.'
I can use holistic approaches like meditation to help my symptoms.'
Many people have the same response to a stressful situation as I am having right'
I am at high risk for post-traumatic-stress disorder because I have acute stress disorder'
I will probably need to be on medication for the rest of my life.'

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 3 of 5

A female client with bulimia is admitted to the mental health unit after she disclosed to a friend that she purges after meals. Which intervention should the nurse implement first?

Correct Answer: B

Rationale: Assessing weight, vital signs, and electrolytes is critical to identify life-threatening complications of bulimia, taking precedence over other interventions.

Extract:

Nurse Notes
0900
Pain assessment completed. The client's pain is 2/10. The client requests sleeping medication for the night. She states that she has horrible thoughts and memories about the house collapsing all the time and that it is keeping her from falling asleep. She states, "I used to be so happy before all of this happened. Now I can't seem to get out of this funk I am in." The client would also prefer to be in a quieter area of the unit as she is currently by the nurses' station and hears talking and alarms constantly.
1100
The nurse reviews the physician's orders for clonazepam and gives the medication as ordered.
1115
Start clonazepam 0.25 mg PO every 12 hours


Question 4 of 5

What nursing interventions are appropriate for the client starting clonazepam? Select all that apply.

Correct Answer: B,C,D

Rationale: Assessing mental status, providing oral care, and screening for orthostatic hypotension are appropriate for clonazepam's CNS effects and side effects like dry mouth. Bathroom assistance, calcium monitoring, and opioid agonists are irrelevant.

Extract:


Question 5 of 5

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

Correct Answer: D

Rationale: Planning daily activities redirects focus from compulsive checking, reducing anxiety and improving function, suitable for OCD-like behaviors.

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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. The nurse engages the client in conversation about her feelings and some of her coping mechanisms. Click to specify which client statement or behavior is most likely associated with each of the listed defense mechanisms.

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