a male client approaches the rn with an angry expression on his face and raises his voice saying my roommate is the most selfish self centered angry p
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Nursing Elites

HESI RN

Quizlet HESI Mental Health

1. A male client approaches the RN with an angry expression on his face and raises his voice, saying, “My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out!” The RN recognizes that the client is using which defense mechanism?

Correct answer: B

Rationale: The correct answer is B: Projection. Projection involves attributing one's own unacceptable feelings or thoughts to others, as seen in the client’s accusations of his roommate’s behavior. In this scenario, the client is projecting his own anger and potential for violence onto his roommate. Choice A, Denial, involves refusing to acknowledge some aspect of reality, which is not evident in the scenario. Choice C, Rationalization, is a defense mechanism where logical reasons are given to justify behaviors that are actually based on unacceptable motives, which is not demonstrated by the client's behavior. Choice D, Splitting, is a defense mechanism where a person sees others as all good or all bad, not applicable in this case as the client is not portraying extreme views of his roommate.

2. 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.

3. The RN is admitting a male client who takes lithium carbonate (Eskalith) twice a day. Which information should the RN report to the HCP immediately?

Correct answer: D

Rationale: Nausea and vomiting are signs of potential lithium toxicity, which is a serious condition requiring immediate attention. These symptoms can indicate a dangerous level of lithium in the body that can lead to severe complications. Short-term memory loss (A), five-pound weight gain (B), and decreased affect (C) are important to monitor but are not as immediately concerning as symptoms of potential toxicity like nausea and vomiting.

4. The mental health team is determining treatment options for a male patient experiencing psychotic symptoms. Which question(s) should the team answer to determine whether a community outpatient or inpatient setting is most appropriate? Select all that apply.

Correct answer: B

Rationale: To determine whether a community outpatient or inpatient setting is most appropriate for a patient experiencing psychotic symptoms, it is crucial to consider if the patient has had experiences with either community or inpatient mental healthcare facilities. This helps assess the familiarity and comfort level of the patient in those settings, aiding in decision-making regarding the level of care needed. Choice A, addressing suicidal thoughts, is important for risk assessment and safety planning but does not directly help in determining the setting appropriateness between community outpatient or inpatient care. Choice C, about the need for a therapeutic environment, is significant but does not specifically assist in deciding between outpatient or inpatient care. Choice D, related to delusions or hallucinations, is relevant in assessing the symptomatology but does not directly guide the choice between community outpatient or inpatient care.

5. A middle-aged female client with no previous psychiatric history is seen in the mental health clinic because her family describes her as having paranoid thoughts. On assessment, she tells the nurse, “I want to find out why these people are stalking me.” Which response should the nurse provide?

Correct answer: A

Rationale: The correct response for the nurse to provide is option A: 'It sounds like this experience is frightening for you.' This response acknowledges the client's feelings and emotions without directly challenging the delusion of being stalked. Option B is incorrect as it directly questions the client's belief, which can lead to increased defensiveness. Option C is incorrect as it denies the client's belief without addressing the underlying fear and can cause the client to feel misunderstood. Option D is incorrect as it directly asks about harm, which may not be the primary concern of the client at this moment.

Similar Questions

A healthcare professional is preparing to provide medication education to a client who has just been prescribed an antipsychotic medication. What should the healthcare professional include in the teaching plan?
During a group session on anger management, a male adolescent client is fidgety, interrupts peers, and talks about his pets at home. What action should the nurse take?
A mental health worker (MHW) is caring for a client with escalating aggressive behavior. Which action by the MHW warrants immediate intervention by the nurse?
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