a client who has agoraphobia a fear of crowds is beginning desensitization with the therapist and the nurse is reinforcing the process which intervent
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Nursing Elites

HESI RN

Mental Health HESI

1. A client who has agoraphobia (a fear of crowds) is starting desensitization therapy with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care?

Correct answer: B

Rationale: Establishing trust by providing a calm and safe environment is crucial for the success of desensitization therapy in clients with agoraphobia. This approach helps the client feel safe and secure, allowing them to gradually confront their fear of crowds. Encouraging positive thoughts (choice A) is beneficial but not as immediately critical as creating a safe space. Progressively exposing the client to larger crowds (choice C) should occur after trust is established and in a controlled manner. Encouraging deep breathing (choice D) is helpful, but creating a safe environment takes precedence to build a foundation for successful desensitization.

2. A client with depression remains in bed most of the day, declines activities, and refuses meals. Which nursing problem has the greatest priority for this client?

Correct answer: C

Rationale: The correct answer is C: 'Refusal to address nutritional needs.' In this scenario, the client's refusal to eat and address their nutritional needs poses an immediate threat to their physical health. Without proper nutrition, the client is at risk of malnutrition and its associated complications. While addressing social isolation, low self-esteem, and loss of interest in diversional activities are important aspects of holistic care for a client with depression, ensuring proper nutrition takes precedence due to the critical impact it has on the client's physical well-being. Therefore, the priority is to address the client's refusal to eat and address their nutritional needs to prevent further deterioration of their health.

3. Narcan was administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate (Vicodin). Within 15 minutes, the client is alert and oriented. In planning nursing care, which intervention has the highest priority at this time?

Correct answer: C

Rationale: Observing the client for further narcotic effects is the priority at this time. It is crucial to monitor the client closely to prevent a relapse of symptoms or potential complications from the overdose. Encouraging fluid intake is important for overall health but not the priority after an overdose. Obtaining serum Vicodin levels may be needed later but does not address the immediate need to monitor for ongoing effects. Determining the reason for the suicide attempt is vital for psychological assessment but should come after ensuring the client's physical stability.

4. 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.

5. A female client with a history of major depressive disorder is experiencing a worsening of symptoms. Which statement by the client indicates a potential risk for suicide?

Correct answer: B

Rationale: The client’s statement about thinking that everyone would be better off without her indicates suicidal ideation. This statement is a significant warning sign for suicide risk and requires immediate intervention. Choices A, C, and D reflect common symptoms of depression but do not directly indicate suicidal thoughts or intentions. Feeling tired, having trouble sleeping, and feeling overwhelmed are typical symptoms of major depressive disorder but do not necessarily suggest an imminent risk of suicide like the statement in option B does.

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