a client is agitated and physically aggressive what action should the rn take first
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Nursing Elites

HESI RN

Quizlet HESI Mental Health

1. 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.

2. A male client with bipolar disorder who began taking lithium carbonate five days ago is complaining of excessive thirst, and the nurse finds him attempting to drink water from the bathroom sink faucet. Which intervention should the nurse implement?

Correct answer: B

Rationale: Encouraging the client to suck on hard candy is the appropriate intervention as it can help alleviate the sensation of excessive thirst, which is a common side effect of lithium. Reporting the client’s serum lithium level to the healthcare provider may be needed if there are signs of lithium toxicity, but the priority here is to address the immediate symptom of excessive thirst. Polydipsia, or excessive thirst, is a known side effect of lithium, but it should not be left unaddressed. Simply telling the client that drinking from the faucet is not allowed does not address the underlying issue of excessive thirst and may lead to further distress.

3. An adolescent with anorexia nervosa is undergoing nutritional therapy. Which finding best indicates that the client is making progress in treatment?

Correct answer: A

Rationale: The correct answer is A. Weight gain is a crucial indicator of progress in the treatment of anorexia nervosa. In individuals with anorexia, restoring and maintaining a healthy weight is a primary goal to address the underlying nutritional deficiencies and health complications associated with the disorder. While choices B, C, and D are positive developments in the client's overall well-being and recovery journey, they are not as directly linked to the core issue of nutritional rehabilitation in anorexia nervosa. Describing a positive body image, engaging in recreational activities, and talking about future goals are important aspects of psychological and emotional recovery, but weight gain is a more immediate and objective measure of progress in treating anorexia nervosa.

4. A client with a history of substance abuse is admitted to the hospital for treatment of a new illness. Which of the following is the most important to assess upon admission?

Correct answer: A

Rationale: Assessing the history of recent drug use is crucial when admitting a client with a history of substance abuse. Understanding recent drug use helps in managing potential withdrawal symptoms, preventing drug interactions with the new treatment, and ensuring appropriate care. Assessing current employment status (choice B) is important for social and financial support but is not as crucial as assessing recent drug use in this scenario. Family history of mental illness (choice C) and recent weight changes (choice D) are also important aspects of assessment but are not as immediate and critical as evaluating recent drug use in a client with a history of substance abuse.

5. When preparing to administer a domestic violence screening tool to a female client, which statement should the RN provide?

Correct answer: D

Rationale: The correct answer is D because screening all clients for domestic abuse helps normalize the process and reduces the stigma, encouraging honest responses. Choice A is not the best option as it may come off as accusatory and can deter the client from being open. Choice B, mentioning state law, may create fear or pressure, affecting the client's response. Choice C focuses on the healthcare provider's needs rather than emphasizing the client's well-being, which may not facilitate open communication.

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