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 male adult is admitted because of an acetaminophen (Tylenol) overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client’s discharge plan?

Correct answer: B

Rationale: The most important information for the nurse to include in the client’s discharge plan is to not take any over-the-counter medication. This is crucial because over-the-counter medications can potentially interact with the damaged liver and worsen the condition. Choices A, C, and D are not as critical in the context of liver damage from an acetaminophen overdose. While diet is important for overall health, specifically for liver damage, avoiding over-the-counter medications takes precedence. Calling the crisis hotline for loneliness and avoiding exposure to large crowds are important considerations but are not directly related to the client's liver damage from the acetaminophen overdose.

3. A client with a recent diagnosis of bipolar disorder is attending a support group for the first time. Which statement made by the client indicates a need for further education about the disorder?

Correct answer: C

Rationale: The correct answer is C because it shows a misconception about bipolar disorder treatment. Stopping medications when feeling better can lead to a relapse or worsening of symptoms. Choice A is correct because medication adherence is crucial in managing bipolar disorder. Choice B is also a good strategy as stress management is important in symptom control. Choice D is a proactive approach to self-awareness and can help in recognizing early signs of mood changes.

4. A client with major depressive disorder is beginning a new antidepressant medication. Which instruction should the nurse include in the discharge teaching?

Correct answer: A

Rationale: The correct instruction the nurse should include in the discharge teaching for a client starting a new antidepressant medication is that “It may take several weeks to notice improvement.” This is because antidepressants often require several weeks before the individual starts to feel the full therapeutic effects. Choice B is incorrect because immediate effects are not typically seen with antidepressants. Choice C is incorrect as stopping the medication abruptly can lead to worsening symptoms or withdrawal effects. Choice D is incorrect as open communication with the therapist is crucial for effective management of major depressive disorder.

5. April, a 10-year-old admitted to inpatient pediatric care, has been getting more and more wound up and is losing self-control in the day room. Time-out does not appear to be an effective tool for April to engage in self-reflection. April’s mother admits to putting her in time-out up to 20 times a day. The nurse recognizes that:

Correct answer: B

Rationale: The correct answer is B: 'Time-out is no longer an effective therapeutic measure.' In this scenario, the excessive use of time-out, up to 20 times a day, indicates that it is no longer effective in helping April self-reflect and control her behavior. Constant use of time-out without achieving the desired outcome suggests the need for alternative therapeutic interventions. Choice A is incorrect because the situation described indicates that time-out is not serving its intended purpose. Choice C is also incorrect as the behavior is not driven by a desire for alone time. Choice D is incorrect and inappropriate as seclusion and restraint should only be considered as a last resort and are not indicated based on the information provided.

Similar Questions

Gilbert, age 19, is described by his parents as a 'moody child' with an onset of odd behavior around age 14, which caused him to suffer academically and socially. Gilbert has lost the ability to complete household chores, is reluctant to leave the house, and is obsessed with the locks on the windows and doors. Due to Gilbert's early and slow onset of what is now recognized as schizophrenia, his prognosis is considered:
A male client tells the RN that he does not want to take the atypical antipsychotic drug, olanzapine (Zyprexa), because of the side effects he experienced when he took it previously. Which statement is best for the RN to provide?
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