a client on the mental health unit is becoming more agitated shouting at the staff and pacing in the hallway when a prn medication is offered the clie
Logo

Nursing Elites

HESI RN

Mental Health HESI Quizlet

1. A client on the mental health unit is becoming more agitated, shouting at the staff, and pacing in the hallway. When a PRN medication is offered, the client refuses the medication and defiantly sits on the floor in the middle of the unit hallway. What nursing intervention should the nurse implement first?

Correct answer: B

Rationale: In situations where a client is agitated and refusing medication, a non-confrontational approach with additional staff can help de-escalate the situation and address the client's behavior safely. Transporting the client to the seclusion room (Choice A) should not be the initial intervention unless the client poses an immediate risk of harm to themselves or others. Taking other clients to the client lounge (Choice C) does not directly address the agitated client's behavior. Administering medication to chemically restrain the client (Choice D) should only be considered after other de-escalation attempts have been made and if there is a significant safety concern.

2. After surgery, a male client with antisocial personality disorder frequently requests a specific nurse be assigned to his care and becomes belligerent when another nurse is assigned. What action should the charge nurse implement?

Correct answer: B

Rationale: The correct action for the charge nurse is to advise the client that assignments are not based on client requests. Clients with antisocial personality disorder may attempt to manipulate situations to their advantage. By setting clear boundaries and explaining that assignments are not based on client preferences, the nurse helps prevent manipulation and maintains a professional approach to care. Reassuring the client about his requests (Choice A) may encourage the inappropriate behavior to continue. Asking the client to explain his requests (Choice C) may further fuel the manipulation by providing an opportunity for the client to justify his actions. Encouraging the client to verbalize feelings (Choice D) does not address the underlying issue of manipulating the assignment process and may inadvertently reinforce the behavior.

3. A female client, who is wearing dirty clothes and has a foul body odor, comes to the clinic reporting feeling scared because she is being stalked. What should the nurse do first?

Correct answer: A

Rationale: When a client presents with signs of distress and potential safety concerns, the priority is to provide a safe environment. Offering a safe place to relax can help the client feel secure and ready for further assessment and support. This action allows the nurse to establish rapport, ensure the client's immediate safety, and create a trusting relationship before delving into the details of the situation. Asking the client to describe why she is being stalked (Choice B) may exacerbate her distress and should come after ensuring her safety. Recommending that the client talk with a social worker (Choice C) is important but should follow immediate safety measures. Assuring the client that the healthcare provider will see her today (Choice D) is less critical than addressing her safety concerns and emotional state.

4. A client is being treated with a tricyclic antidepressant (TCA). Which side effect should the nurse monitor for?

Correct answer: A

Rationale: The correct answer is A: Constipation and urinary retention. Tricyclic antidepressants (TCAs) are known to have anticholinergic side effects, which include constipation and urinary retention. These side effects occur due to the inhibition of cholinergic receptors, leading to decreased gastrointestinal motility and relaxation of the detrusor muscle in the bladder. Choices B, C, and D are incorrect because increased appetite, weight loss, sedation, blurred vision, insomnia, and dry mouth are not typically associated with the use of TCAs. Monitoring for constipation and urinary retention is essential to prevent complications and ensure the client's safety.

5. Which actions are likely to help promote the self-esteem of a male client with major depression?

Correct answer: C

Rationale: Including the client in determining the treatment protocol is the most suitable action to promote the self-esteem of a male client with major depression. This approach empowers the client, involves him in decision-making regarding his care, and fosters a sense of control and self-worth. Option A, asking about his long-term goals, may not directly address his immediate self-esteem needs related to his current condition. Option B, discussing the challenges of his medical condition, may inadvertently focus on negative aspects and potentially lower self-esteem. Option D, encouraging engagement in recreational therapy, is beneficial but may not directly address the client's sense of control and self-worth in decision-making related to his treatment.

Similar Questions

A male client with schizophrenia tells the RN that he is being watched and that the television is speaking directly to him. Which response by the RN is appropriate?
What assessment questions should the nurse ask when attempting to determine a teenager’s mental health resilience? Select all that apply.
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?
During admission to the psychiatric unit, a female client is extremely anxious and states that she is worried about the sun coming up the next day. What intervention is most important for the RN to implement during the admission process?
The client is preparing to discontinue the use of a sedative-hypnotic medication. Which instruction should the nurse include?

Access More Features

HESI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses