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HESI Mental Health
1. A client with obsessive-compulsive disorder (OCD) spends several hours a day washing his hands. What is the best nursing intervention?
- A. Restrict the client's access to soap and water.
- B. Encourage the client to discuss their compulsions.
- C. Allow the client to continue the behavior until ready to stop.
- D. Schedule activities that distract the client from hand-washing.
Correct answer: B
Rationale: Encouraging the client to discuss their compulsions is the best nursing intervention when caring for a client with OCD who spends excessive time on hand-washing. This approach can help the client identify underlying anxieties and triggers associated with the compulsive behavior. Restricting access to soap and water (Choice A) can lead to increased anxiety and worsen the obsession. Allowing the client to continue the behavior (Choice C) can perpetuate the compulsive cycle. Scheduling distracting activities (Choice D) may provide temporary relief but does not address the root cause of the behavior.
2. A male client with delirium becomes disoriented and confused in his room at night. The best initial nursing intervention is to:
- A. Move the client next to the nurse's station
- B. Use an indirect light source and turn off the television
- C. Keep the television and a soft light on during the night
- D. Play soft music during the night, and maintain a well-lit room
Correct answer: B
Rationale: The best initial nursing intervention for a male client with delirium who becomes disoriented and confused in his room at night is to use an indirect light source and turn off the television. This approach helps to reduce stimulation and confusion, aiding in the client's orientation and comfort. Moving the client next to the nurse's station (Choice A) may not address the root cause of disorientation and could disrupt the client's routine. Keeping the television and a soft light on (Choice C) may further contribute to the client's confusion. Playing soft music and maintaining a well-lit room (Choice D) may not be as effective in reducing stimulation and promoting orientation as using an indirect light source and turning off the television.
3. A 72-year-old female client is admitted to the psychiatric unit with a diagnosis of major depression. Which statement by the client should be of greatest concern to the nurse and require further assessment?
- A. "I will die if my cat dies."
- B. "I don't feel like eating this morning."
- C. "I just went to my friend's funeral."
- D. "Don't you have more important things to do?"
Correct answer: A
Rationale: Sometimes a client will use an analogy to describe themselves, and (A) would be an indication for conducting a suicide assessment. (B) could have a variety of etiologies, and while further assessment is indicated, this statement does not indicate potential suicide. The normal grief process differs from depression, and at this client's age, peer/cohort deaths are more frequent, so (C) would be within normal limits. (D) is an expression of low self-esteem typical of depression. Choices (B), (C), and (D) are examples of decreased energy and mood levels which would negate suicide ideation at this time.
4. A client's medication sheet contains a prescription for sertraline (Zoloft). To ensure safe administration of the medication, a nurse would administer the dose:
- A. On an empty stomach
- B. At the same time each evening
- C. Evenly spaced around the clock
- D. As needed when the client complains of depression
Correct answer: B
Rationale: The correct answer is B: 'At the same time each evening.' Sertraline should be administered at the same time each evening to maintain steady drug levels and effectiveness. Choice A is incorrect because sertraline can be taken with or without food. Choice C is incorrect as sertraline does not need to be spaced around the clock. Choice D is incorrect as sertraline is a scheduled medication and should not be taken on an as-needed basis for complaints of depression.
5. A client with borderline personality disorder is admitted to the psychiatric unit after a suicide attempt. The client frequently expresses feelings of emptiness and fears of abandonment. What is the most therapeutic nursing approach for this client?
- A. Encourage the client to participate in all group activities.
- B. Set clear and consistent boundaries while providing empathy.
- C. Reassure the client that the staff will not abandon them.
- D. Explore the client's past relationships in depth.
Correct answer: B
Rationale: The most therapeutic nursing approach for a client with borderline personality disorder, who frequently expresses feelings of emptiness and fears of abandonment, is to set clear and consistent boundaries while providing empathy. This approach helps manage the client's fear of abandonment and feelings of emptiness, which are common in borderline personality disorder. Option A may overwhelm the client in a group setting without addressing their specific needs. Option C, while well-intentioned, may not fully address the underlying issues and may create dependency. Option D delves into the client's past relationships, which may be inappropriate and trigger emotional distress in a vulnerable client.
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