Quizlet HESI Mental Health

Questions 42

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Quizlet HESI Mental Health Questions

Question 1 of 5

The RN documents the mental status of a female client who has been hospitalized for several days by court order. The client states, "I don't need to be here," and tells the RN that she believes that the TV talks to her. The RN should document these assessment statements in which section of the mental status exam?

Correct Answer: A

Rationale: The client's statement of not needing to be hospitalized and her belief that the TV talks to her indicate impaired insight and judgment. Insight and judgment evaluate the client's awareness of their condition and ability to make sound decisions. Mood and affect assess emotional state, remote memory evaluates recall of past events, and level of concentration assesses attention and focus, none of which directly address the client's lack of insight and judgment in this scenario.

Question 2 of 5

A client is agitated and physically aggressive. What action should the RN take first?

Correct Answer: D

Rationale: In a situation where a client is agitated and physically aggressive, the priority for the RN is to ensure the safety of the client and others. Seeking assistance from other staff members is crucial as it allows for a prompt response to manage the situation effectively and according to the facility's protocol. Choices A, B, and C do not address the immediate need for safety or involve the collaboration of other staff members, which is essential in handling aggressive behaviors in a healthcare setting.

Question 3 of 5

A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The nurse also determines that the client is homeless and slightly suspicious. This client's treatment plan should include what priority problem?

Correct Answer: D

Rationale: The correct answer is 'D: Acute confusion.' In the given scenario, the client is disoriented, disorganized, and confused, indicating acute confusion. This is a priority issue to address for immediate safety and appropriate care. Option A, self-care deficit, is not the priority as the client's safety and mental status take precedence. Option B, disturbed sensory perception, does not align with the client's presentation of confusion. Option C, ineffective community coping, is not the immediate concern as the client's cognitive state needs urgent attention.

Question 4 of 5

A client who is being treated with lithium carbonate for bipolar disorder develops diarrhea, vomiting, and drowsiness. What action should the nurse take?

Correct Answer: A

Rationale: Diarrhea, vomiting, and drowsiness in a client being treated with lithium carbonate for bipolar disorder may indicate lithium toxicity. The nurse should promptly notify the healthcare provider to ensure immediate medical intervention. The correct action is to prepare for the administration of an antidote if necessary. Holding the medication (Choice B) could delay necessary treatment. Considering the symptoms as normal side effects (Choice C) is incorrect as they suggest a potential serious issue. Notifying the healthcare provider before the next administration of the drug (Choice D) may delay urgent intervention required for lithium toxicity.

Question 5 of 5

An adolescent with a history of bipolar disorder is hospitalized during a manic episode. Which intervention is most appropriate for the nurse to include in the care plan?

Correct Answer: B

Rationale: During a manic episode, individuals with bipolar disorder may experience heightened energy levels, decreased need for sleep, and racing thoughts. Providing a quiet and structured environment is crucial in managing these symptoms as it helps reduce external stimuli, prevent overstimulation, and promote a sense of calmness. Encouraging high levels of physical activity may exacerbate the manic symptoms by further increasing stimulation and excitement. Engaging the client in creative arts activities might be beneficial during stable periods but may not be the most appropriate intervention during a manic episode. Allowing the client to make decisions about their schedule could potentially lead to impulsivity and poor judgment, which are common characteristics of mania.

Similar Questions

An adolescent with a history of bipolar disorder is hospitalized during a manic episode. Which intervention is most appropriate for the nurse to include in the care plan?
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