a homeless client who reports feeling sad and depressed tells the mental health nurse that in the past 2 days she has only had 4 hours of sleep which
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Nursing Elites

HESI RN

Quizlet Mental Health HESI

1. What action is most important for the RN to implement within the first 24 hours after treatment is initiated for a homeless client who reports feeling sad and depressed and has only had 4 hours of sleep in the past 2 days?

Correct answer: A

Rationale: A: Addressing the client’s immediate need for rest and sleep is crucial for stabilization and recovery. It is essential to prioritize the client's physical well-being and provide the opportunity for adequate rest. B: Group therapy and coping skills are important but secondary to ensuring immediate needs are met. C: Discharge planning is important but should follow stabilization of the client’s immediate needs. D: Encouraging verbalization of feelings is supportive but not as urgent as addressing basic needs like rest.

2. 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.

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 action is most important for the nurse to take?

Correct answer: D

Rationale: The most important action for the nurse to take in this scenario is to offer the client a safe place to relax before interviewing her. The client's disheveled appearance and foul body odor suggest she may be in distress or facing challenging circumstances. By providing her with a safe and comfortable environment to relax, the nurse can help alleviate some of her distress and establish trust. This approach is crucial as the client is already feeling scared due to being stalked, indicating underlying mental health concerns. Assuring the client that she will be seen by a healthcare provider today (choice A) may not address her immediate need for safety and comfort. Recommending she speaks with a social worker (choice B) may be beneficial later but does not address the immediate need for a safe space. Asking the client if she feels comfortable sharing why she is being stalked (choice C) is not appropriate as the priority is ensuring her safety and comfort first.

4. A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and lack of motivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?

Correct answer: B

Rationale: Teaching the client to develop a plan for daily structured activities is the most effective intervention in this scenario. This intervention helps address psychomotor retardation and enhances motivation and functioning. By structuring the client's day, it can provide a sense of purpose, routine, and accomplishment. Option A, providing education on methods to enhance sleep, may be helpful but does not directly address the client's overall functioning. Option C, suggesting the client develop a list of pleasurable activities, may provide temporary relief but may not address the core symptoms of major depressive disorder. Option D, encouraging the client to exercise, can be beneficial, but in this case, addressing the lack of structure and motivation through a daily plan is more appropriate.

5. 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.

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