HESI RN
Quizlet HESI Mental Health
1. A female client with obsessive-compulsive personality disorder is admitted to the hospital for a cardiac catheterization. The afternoon before the procedure, the client begins to keep detailed notes of the nursing care she is receiving and reports her findings to the RN at bedtime. What action should the nurse implement?
- A. Explain to the client that her behavior invades the rights of the nursing staff.
- B. Ask the client to explain why she is keeping a detailed record of her nursing care.
- C. Teach the client strategies to control her obsessive-compulsive behavior.
- D. Encourage the client to express her feelings regarding the upcoming procedure.
Correct answer: B
Rationale: Asking the client to explain why she is keeping a detailed record of her nursing care is the most appropriate action for the nurse to take in this situation. Understanding the client’s motivations for keeping detailed records can provide insight into her obsessive-compulsive behaviors and help manage them effectively. This approach allows for a non-confrontational exploration of the behavior. Choice A is incorrect because it may be perceived as confrontational and does not address the underlying reasons for the behavior. Choice C is incorrect because teaching strategies to control behavior should come after understanding the client's motives. Choice D is incorrect as it does not directly address the behavior of keeping detailed records, which is the immediate concern that needs to be addressed.
2. The nurse is assessing a client who has schizophrenia and is exhibiting symptoms of paranoia. Which behavior would the nurse most likely observe?
- A. The client is seen as unmotivated and withdrawn.
- B. The client is preoccupied with a fear of being harmed.
- C. The client displays a blunted affect and lacks emotional response.
- D. The client avoids group activities and shows decreased appetite.
Correct answer: B
Rationale: In clients with paranoia, they typically exhibit an intense fear of being harmed, persecuted, or targeted by others. This fear often dominates their thoughts and can significantly impact their daily functioning and interactions. Choice A, being unmotivated and withdrawn, is more indicative of negative symptoms of schizophrenia, such as avolition and social withdrawal. Choice C, displaying a blunted affect and lacking emotional response, is associated with flat affect, a symptom commonly seen in schizophrenia but not specific to paranoia. Choice D, avoiding group activities and showing decreased appetite, may be related to various symptoms or side effects, but it is not a defining characteristic of paranoia in schizophrenia.
3. A client who is known to abuse drugs is admitted to the psychiatric unit. Which medication should the nurse anticipate administering to a client who is exhibiting benzodiazepine withdrawal symptoms?
- A. Diphenhydramine (Benadryl)
- B. Perphenazine (Trilafon)
- C. Isocarboxazid (Marplan)
- D. Chlordiazepoxide (Librium)
Correct answer: D
Rationale: Chlordiazepoxide (Librium) is the correct choice for managing benzodiazepine withdrawal symptoms. Benzodiazepines are drugs that can lead to physical dependence, and abrupt discontinuation can result in withdrawal symptoms. Chlordiazepoxide, a benzodiazepine itself, is often used in a controlled manner to taper off the drug gradually and manage withdrawal symptoms effectively. Choices A, Diphenhydramine, and B, Perphenazine, are not typically used to manage benzodiazepine withdrawal. Choice C, Isocarboxazid, is a monoamine oxidase inhibitor (MAOI) used in the treatment of depression and not indicated for benzodiazepine withdrawal.
4. A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone (Risperdal). When the client walks to the nurse’s station in a literally contracted position, he states that something has made his body contort into a monster. What action should the nurse take?
- A. Medicate the client with the prescribed antipsychotic thioridazine (Mellaril).
- B. Offer the client a prescribed physical therapy hot pack for muscle spasms.
- C. Direct the client to occupational therapy to distract him from somatic complaints.
- D. Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia.
Correct answer: D
Rationale: The correct action for the nurse to take in this situation is to administer the prescribed anticholinergic benztropine (Cogentin) for dystonia. The client's symptoms of body contortion and feeling like a monster are indicative of acute dystonia, which can be a side effect of antipsychotic medications like risperidone. Benztropine can help alleviate these acute dystonic reactions. Choice A is incorrect because changing the antipsychotic medication at this point is not indicated. Choice B is not appropriate as the client's symptoms are likely due to acute dystonia rather than muscle spasms. Choice C is also not the best course of action as the client needs immediate intervention for the acute dystonic reaction.
5. Which client statement suggests to the nurse that the client is using the defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit?
- A. I am here because the police thought I was doing something wrong
- B. At least I hit the wall instead of hitting the psychiatric aide
- C. I want to be here because I know it is the best psychiatric facility
- D. Don’t believe everything my family tells you, I am not crazy
Correct answer: B
Rationale: The correct answer is B because the client is projecting their aggressive impulses onto an inanimate object, the wall, instead of accepting their own feelings. This statement reflects the defense mechanism of projection. Choice A is not projection; it is an explanation of why the client is there. Choice C indicates acceptance of the facility and does not involve projection. Choice D is a denial statement rather than projection.
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