Mental Health HESI 2023

Correct Answer: B

Rationale: When a client with bipolar disorder expresses a desire to stop taking lithium because they feel fine, the nurse's initial action should be to remind the client of the importance of lithium. This approach helps educate the client about the necessity of medication adherence in managing bipolar disorder. Agreeing with the client or immediately arranging a psychiatric evaluation may not address the root issue of medication non-adherence. Asking the healthcare provider to discontinue the prescription without further assessment and intervention could potentially jeopardize the client's stability and treatment plan.

Correct Answer: C

Rationale: Tremors are an early sign of alcohol withdrawal. They are caused by hyperactivity of the autonomic nervous system and are a common symptom during the early stages of withdrawal. Monitoring tremors is crucial as they can progress to more severe symptoms if not managed effectively. Seizures (Choice A) typically occur later in the withdrawal process and are a more severe symptom. Visual hallucinations (Choice B) usually manifest after tremors and are considered a mid-stage symptom. Delirium tremens (Choice D) is a severe form of alcohol withdrawal that typically occurs 2-3 days after the last drink, characterized by confusion, disorientation, and severe autonomic hyperactivity.

Correct Answer: D

Rationale: Explaining that it may take up to 8 weeks for the medication to take full effect provides the client with a realistic expectation. SSRI medications typically require time to build up in the body and exert their therapeutic effects. Choice A is incorrect as it underestimates the time frame required for the medication to work. Choice B is incorrect as SSRIs do not produce immediate effects. Choice C is incorrect as it falsely states that the medication works immediately, which is not true for SSRIs.

Correct Answer: C

Rationale: A sudden improvement in mood and declaring being cured can be warning signs of a decision to attempt suicide. Therefore, the appropriate action would be to increase the level of suicide precautions to ensure the safety of the client. This can involve closer monitoring and restriction of items that could be harmful. Choices A, B, and D are incorrect as they do not address the potential risk of suicide that may be present with the sudden change in behavior.

Correct Answer: B

Rationale: The nurse should initiate a referral based on moderate levels of anxiety (B) as the client reports feeling nervous all the time, sleep disturbances, poor appetite, and difficulty solving problems. These symptoms are indicative of significant anxiety levels. The client does not mention symptoms related to altered thought processes (A) or inadequate social support (C). There is insufficient information to suggest altered health maintenance (D) as a reason for referral in this scenario.