RN Hesi Mental Health

Extract:

Question 1 of 5

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

Correct Answer: A

Rationale: Spending time in silence creates a supportive environment, allowing the client to communicate at her pace, addressing delayed responses.

Question 2 of 5

During a routine assessment at an outpatient clinic, the nurse notes that a client has abdominal obesity and a high waist-hip ratio, with a body mass index of 32 kg/m2. Which action(s) should the nurse take in response to these findings? (Select all that apply.)

A. Measure the client's blood pressure in both arms. B. Screen for a family history of diabetes mellitus. C. Arrange for immediate transport to a medical facility. D. Advise the client to restrict fluids and keep feet elevated. E. Discuss the importance of a regular exercise program.

Correct Answer: A,B,E

Rationale: Measuring blood pressure assesses hypertension risk, screening for diabetes history addresses increased risk from obesity, and discussing exercise helps manage obesity-related risks. Immediate transport is not indicated, and fluid restriction/elevation is irrelevant without edema.

Question 3 of 5

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

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

Correct Answer: A

Rationale: Spending time in silence creates a supportive environment, allowing the client to communicate at her pace, addressing delayed responses.

Question 4 of 5

A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?

A. Compromised family coping. B. Ineffective sexual patterns. C. Impaired environmental interpretation. D. Disturbed sensory perception.

Correct Answer: D

Rationale: Delusional beliefs indicate disturbed sensory perception, the priority problem requiring psychiatric evaluation.

Question 5 of 5

A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?

A. Assist the client with relaxation techniques in the group. B. Escort the client from the group to reduce stimuli. C. Provide education about ways to cope with anxiety. D. Ask the client to describe and identify the source of the feelings.

Correct Answer: A

Rationale: Assisting with relaxation techniques in the group provides immediate anxiety relief and support, suitable for acute anxiety.