Mental Health HESI

Correct Answer: A

Rationale: The correct answer is A: Constipation and urinary retention. Tricyclic antidepressants (TCAs) are known to have anticholinergic side effects, which include constipation and urinary retention. These side effects occur due to the inhibition of cholinergic receptors, leading to decreased gastrointestinal motility and relaxation of the detrusor muscle in the bladder. Choices B, C, and D are incorrect because increased appetite, weight loss, sedation, blurred vision, insomnia, and dry mouth are not typically associated with the use of TCAs. Monitoring for constipation and urinary retention is essential to prevent complications and ensure the client's safety.

Correct Answer: D

Rationale: The best intervention for a male client with schizophrenia displaying echolalia, which is disruptive to others, is for the nurse to escort the client to his room. Echolalia, the constant repetition of others' words, can be disruptive in a communal setting. By guiding the client to a private space like his room, the nurse helps manage the behavior without isolating or medicating the client unnecessarily. Avoiding acknowledging the behavior (Choice A) does not address the issue, isolating the client (Choice B) may exacerbate feelings of exclusion, and administering a PRN sedative (Choice C) should be reserved for situations where there is imminent risk or severe agitation, not for managing echolalia.

Correct Answer: D

Rationale: In this scenario, the client is experiencing hallucinations and symptoms of alcohol withdrawal. Lorazepam (Ativan) is the appropriate choice as it helps manage withdrawal symptoms, including hallucinations and elevated blood pressure in alcohol-dependent clients. Haloperidol (Haldol) (Choice A) is an antipsychotic but is not the first-line treatment for alcohol withdrawal symptoms. Thiamine (Vitamin B1) (Choice B) is essential in alcohol withdrawal treatment for preventing Wernicke's encephalopathy, but in this case, addressing the acute withdrawal symptoms is the priority. Diphenhydramine (Benadryl) (Choice C) is an antihistamine that may help with itching or mild anxiety but is not the preferred choice for managing alcohol withdrawal symptoms like hallucinations and elevated blood pressure.

Correct Answer: C

Rationale: The correct answer is C: 'Refusal to address nutritional needs.' In this scenario, the client's refusal to eat and address their nutritional needs poses an immediate threat to their physical health. Without proper nutrition, the client is at risk of malnutrition and its associated complications. While addressing social isolation, low self-esteem, and loss of interest in diversional activities are important aspects of holistic care for a client with depression, ensuring proper nutrition takes precedence due to the critical impact it has on the client's physical well-being. Therefore, the priority is to address the client's refusal to eat and address their nutritional needs to prevent further deterioration of their health.

Correct Answer: B

Rationale: B: Before starting Disulfiram therapy, it is crucial for clients to be alcohol-free for a minimum of 12 hours to prevent adverse reactions. A: Admitting substance abuse is important, but it is not directly linked to the initiation of Disulfiram therapy. C: Attending Alcoholics Anonymous meetings is beneficial for support but not a specific requirement for starting Disulfiram. D: The focus of Disulfiram therapy is on alcohol abstinence, so abstaining from heroin or cocaine is not directly related to this medication.