within several days of hospitalization a client is repeatedly washing the top of the same table which initial intervention is best for the nurse to im
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HESI Mental Health

1. Within several days of hospitalization, a client is repeatedly washing the top of the same table. Which initial intervention is best for the nurse to implement to help the client cope with anxiety related to this behavior?

Correct answer: C

Rationale: Initially, the nurse should allow time for the ritualistic behavior (C) to prevent anxiety. Administering an antianxiety medication (A) may help reduce the client's anxiety temporarily but will not address the underlying issue of ineffective coping mechanisms leading to the behavior. While assisting the client in identifying triggers (B) is important for long-term therapy, the immediate focus should be on managing the behavior. Teaching relaxation and thought-stopping techniques (D) is beneficial but might be more effective once the client is more stable and receptive to learning new coping strategies.

2. A client, who is on a 30-day commitment to a drug rehabilitation unit, asks the nurse if he can go for a walk on the grounds of the treatment center. When he is told that his privileges do not include walking on the grounds, the client becomes verbally abusive. Which approach will the nurse take?

Correct answer: C

Rationale: (C) is the correct approach in this situation as it reinforces unit rules, setting clear boundaries and expectations. By reminding the client of the unit rules, the nurse is helping to maintain a safe and structured environment within the drug rehabilitation unit. (A) is unnecessary since the client's behavior does not warrant immediate physical intervention. (B) is not ideal because the client's privileges have already been explained, and suggesting he speak to his healthcare provider may not address the immediate issue. (D) is not appropriate as addressing inappropriate behavior is essential in a therapeutic setting.

3. A client with obsessive-compulsive disorder (OCD) is hospitalized for treatment. Which intervention is most important for the LPN/LVN to include in the client's plan of care?

Correct answer: D

Rationale: The correct intervention for a client with OCD is to work with them to gradually reduce the frequency of compulsive behaviors. This approach helps the client manage their condition effectively without causing undue distress. Allowing the client to engage in compulsive behaviors can reinforce the disorder rather than alleviate it. Encouraging the client to ignore compulsive behaviors does not address the core issue of OCD. While helping the client understand the purpose of compulsive behaviors can be beneficial, actively working to reduce these behaviors is more crucial in the treatment of OCD.

4. A 46-year-old female client has been on antipsychotic neuroleptic medication for the past three days. She has had a decrease in psychotic behavior and appears to be responding well to the medication. On the fourth day, the client's blood pressure increases, she becomes pale and febrile, and demonstrates muscular rigidity. Which action will the nurse initiate?

Correct answer: B

Rationale: These symptoms are indicative of neuroleptic malignant syndrome (NMS), which is a severe and life-threatening reaction to neuroleptic drugs. The major symptoms include fever, rigidity, autonomic instability, and encephalopathy. Respiratory failure, cardiovascular collapse, arrhythmias, and/or renal failure can lead to death. This is an emergency situation requiring immediate critical care, thus the correct action is to transfer the client to the ICU (B). Seizure precautions (A) are not relevant in this scenario. Merely describing the symptoms to the charge nurse and documenting them (C) or taking no action assuming these are common side effects (D) fail to address the critical nature of the situation and the urgency of immediate intervention.

5. A client with bipolar disorder, manic phase, is admitted to the psychiatric unit. Which meal is most appropriate for this client?

Correct answer: B

Rationale: A chicken salad sandwich (B) is the most appropriate choice as it is easy to eat on the go, which is important for a client in the manic phase who may have difficulty sitting still for a meal. Spaghetti and meatballs (A) and steak and potatoes (C) require more time and effort to eat, which may be challenging for a client experiencing mania. While hamburger and fries (D) could be an option, a chicken salad sandwich is a healthier and more manageable choice, considering the client's potential hyperactive state.

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