Mental Health HESI

Correct Answer: D

Rationale: The best nursing action in this scenario is to redirect the client by encouraging him to read from the handout. This approach helps refocus the client's attention on the topic being discussed, which is anger management. Choice A is not appropriate as it may disrupt the group session and does not address the client's behavior. Choice B, while important in understanding the client's background, does not address the immediate disruptive behavior. Choice C involves others to manage the client's behavior instead of direct intervention by the nurse, which may not be effective in this situation.

Correct Answer: B

Rationale: The correct answer is B: Moderate anxiety. When a client presents with symptoms such as shortness of breath, dizziness, and a fear of dying, it indicates moderate anxiety. Anxiety can manifest physically with symptoms like these. Mood disturbance (choice A) refers to a change in mood, while altered thoughts (choice C) relate to cognitive changes. Social isolation (choice D) involves a lack of social interaction, which is not the primary concern in this scenario where the client is experiencing acute anxiety symptoms.

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.

Correct Answer: A

Rationale: In individuals with bipolar disorder experiencing mania, impulsivity and poor judgment are common. Delaying business decisions until the mania subsides is crucial to prevent impulsive and potentially harmful financial choices. Choice B, identifying feelings associated with behaviors, may be important but does not directly address the immediate need to prevent risky financial decisions. Seeking legal counsel (Choice C) may be appropriate in some situations but is not the priority in managing acute mania. Describing why he feels fearful about finances (Choice D) is relevant for understanding emotions but does not address the immediate risk of impulsive financial actions during mania.

Correct Answer: C

Rationale: Ineffective breathing pattern is the highest priority nursing problem in this scenario because aspiration of a caustic material can lead to serious airway and respiratory issues. This poses an immediate threat to the client's life and requires urgent intervention to ensure adequate oxygenation and ventilation. The other options, such as Impaired comfort, Risk for injury, and Ineffective coping, are important but are secondary concerns compared to the critical nature of respiratory compromise in this situation.