a client tells the rn that he has an iq of 400 and is a genius and an inventor he also reports that he is married to a female movie star and thinks th
Logo

Nursing Elites

HESI RN

Quizlet Mental Health HESI

1. A client tells the RN that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. What is the priority nursing problem for admission to the psychiatric unit?

Correct answer: C

Rationale: The priority nursing problem for admission to the psychiatric unit is 'Disturbed sensory perception.' This choice is correct because the client's delusional beliefs about having an IQ of 400+, being a genius and an inventor, being married to a movie star, and suspecting his brother of wanting a sexual relationship with her indicate a significant disturbance in sensory perception. The client's perceptions are not based in reality, indicating a need for immediate intervention to address these distorted beliefs. Choices A, B, and D are incorrect: 'Ineffective sexual patterns' is not the priority as the client's delusions go beyond just sexual relationships, 'Impaired environmental interpretation' does not capture the primary issue of distorted perceptions, and 'Compromised family coping' is not the priority concern in this scenario compared to the severe sensory perception disturbances displayed by the client.

2. An antidepressant medication is prescribed for a client who reports sleeping only 4 hours in the past 2 days and weight loss of 9 lbs within the last month. Which client goal is most important to achieve within the first three days of treatment?

Correct answer: B

Rationale: The most important goal to achieve within the first three days of treatment is to ensure the client can sleep at least 6 hours a night. Adequate sleep is essential for stabilizing mood and improving overall functioning. Improving sleep patterns is crucial to address the reported sleep deficit and weight loss associated with depression. Choice A is not as urgent as improving sleep patterns. Choice C is important but not as immediate as addressing the sleep deficit. Choice D is unrelated to the immediate treatment goal of improving sleep and managing symptoms of depression.

3. What should the nurse initially assess when a high school girl reveals engaging in self-induced vomiting as a weight-control measure?

Correct answer: B

Rationale: The correct answer is assessing the frequency of bingeing and purging behaviors. This assessment is crucial in understanding the severity of the eating disorder and developing an appropriate treatment plan. Options A, C, and D are not the initial priority when dealing with a student engaging in harmful behaviors related to eating disorders. While weight and height, family relationships, and academic performance are important aspects to consider, the immediate focus should be on evaluating the behaviors directly linked to the reported issue.

4. Which therapeutic communication statement might a psychiatric-mental health registered nurse use when a patient's nursing diagnosis is altered thought processes?

Correct answer: C

Rationale: Choice C is the correct answer because it acknowledges the patient's experience of hearing voices, showing empathy and exploring the content of the hallucinations. This type of therapeutic communication encourages the patient to express their thoughts and feelings without judgment. Choices A, B, and D are incorrect because they either deny the patient's experience, dismiss the hallucinations as not real, or suggest eliminating them, which can be perceived as invalidating the patient's feelings and experiences.

5. The client is being educated by the healthcare provider about starting a prescribed abstinence therapy with disulfiram (Antabuse). What information should the client understand?

Correct answer: B

Rationale: The correct answer is B. Before starting disulfiram therapy (Antabuse), the client must comprehend the need to remain alcohol-free for a minimum of 12 hours. This is crucial to prevent the unpleasant and potentially dangerous reactions that can occur with concurrent alcohol consumption while on disulfiram. Choice A is incorrect because it mentions heroin or cocaine use, which is not the primary focus when initiating disulfiram therapy. Choice C is incorrect as it suggests therapy sessions, which are not specifically required before starting disulfiram. Choice D is incorrect as there is no need to disclose disulfiram therapy to others, but rather to adhere to the abstinence requirement.

Similar Questions

Following involvement in a motor vehicle collision, a middle-aged adult client is admitted to the hospital with multiple facial fractures. The client’s blood alcohol level is high on admission. Which PRN prescription should be administered if the client begins to exhibit signs and symptoms of delirium tremens (DT)?
A client who is admitted to the mental health unit reports shortness of breath and dizziness. The client tells the nurse, “I feel like I’m going to die.” Which nursing problem should the nurse include in this client’s plan of care?
A client is admitted for bipolar disorder and alcohol withdrawal, depressive phase. Based on which assessment finding will the RN withhold the clonidine (Catapres) prescription?
Kyle, a patient with schizophrenia, began taking the first-generation antipsychotic haloperidol (Haldol) last week. One day you find him sitting very stiffly and not moving. He is diaphoretic, and when you ask if he is okay, he seems unable to respond verbally. His vital signs are: BP 170/100, P 110, T 104.2°F. What is the priority nursing intervention? Select all that apply.
A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The RN also determines that the client is homeless and is exhibiting suspiciousness. The client’s plan of care should include what priority problem?

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