a client who is admitted with a closed head injury after a fall has a blood alcohol level bal of 028 28 and is difficult to arouse which intervention
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HESI RN

Mental Health HESI Quizlet

1. A client who is admitted with a closed head injury after a fall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the nurse identify as the priority?

Correct answer: A

Rationale: Maintain the patient's airway is the priority for a client who is intoxicated and obtunded.

2. 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.

3. The nurse completes an assessment of a client who is experiencing intimate partner violence (IPV). Which finding of the injuries should the nurse include in the documentation?

Correct answer: B

Rationale: In cases of intimate partner violence (IPV), documenting injuries is essential for legal and medical purposes. Photographs provide concrete and objective evidence of the injuries, leaving no room for interpretation or doubt. This visual documentation can be crucial in legal proceedings and serve as a critical component in ensuring the safety and well-being of the client. The significant other's statement (Choice A) may not accurately reflect the client's injuries and could be biased. A general description (Choice C) lacks the specificity and objectivity that photographs offer. Summarizing the client's feelings (Choice D) is important for emotional support but does not provide the concrete evidence needed in documenting IPV cases.

4. The RN is teaching a client about the initiation of the prescribed abstinence therapy using disulfiram (Antabuse). What information should the client acknowledge understanding?

Correct answer: B

Rationale: The correct answer is B: "Remain alcohol-free for 12 hours prior to the first dose." It is essential for the client to understand the importance of abstaining from alcohol for at least 12 hours before starting disulfiram to prevent potential adverse reactions. Choice A is incorrect because disulfiram is specifically used to deter alcohol consumption, not heroin or cocaine use. Choice C is not directly related to the initiation of disulfiram therapy and attending AA meetings is not a requirement for taking disulfiram. Choice D is irrelevant and unnecessary for the initiation of disulfiram therapy.

5. 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.

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