Question

A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The nurse also determine the client is homeless and is exhibiting suspiciousness. This client's plan of care should include what priority problem?

Answer 1

Correct Answers:

Acute confusion.

Rationale :

🔷 Acute confusion is a priority because the client is disoriented, disorganized, and confused—signs of impaired cognition.

🔷 It represents a safety concern that requires immediate assessment and management to reduce risk of harm.

🔷 The client’s homelessness and suspiciousness further increase vulnerability.

🔷 Treating confusion can help guide further evaluation of underlying causes such as substance use or psychosis.

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Answer 2

Correct Answers:

Escort the client from the group to reduce stimuli.

Rationale :

✔ In severe anxiety, the client's perceptual field is greatly narrowed and environmental stimuli can worsen distress.

✔ Removing the client from the group setting minimizes overstimulation and promotes calming.

✔Once stabilized, other therapeutic strategies like relaxation can be implemented.

✔ The priority in severe anxiety is safety and reduction of anxiety-provoking stimuli.

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Answer 3

Correct Answers:

Methamphetamine.

Rationale :

♦ Methamphetamine is a powerful stimulant that increases heart rate, blood pressure, and cardiac workload.

♦ Chronic use is strongly associated with increased risk for myocardial infarction and cardiomyopathy.

♦ It causes vasoconstriction, leading to ischemia and arrhythmias.

♦ Other substances like alcohol or benzodiazepines depress the CNS and are less acutely cardiotoxic.

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Answer 4

Correct Answers:

Stimulation and dilated pupils

Rationale :

⬖ Cocaine is a central nervous system stimulant that causes increased sympathetic activity.

⬖ Expected findings include tachycardia, dilated pupils, hyperactivity, and euphoria.

⬖ These effects can persist for several hours and pose safety risks.

⬖ Early recognition allows for prompt treatment and monitoring

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Answer 5

Correct Answers:

"The voices are telling me to kill the next person I see."

Rationale :

💎 This is a classic persecutory delusion, a fixed false belief with no basis in reality.

💎 Delusions are core symptoms of schizophrenia and often revolve around paranoia or grandiosity.

💎 Identifying delusions helps direct antipsychotic treatment and therapeutic response.

💎 Visual hallucinations like "snakes on the wall" indicate different symptoms (hallucinations, not delusions)

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Answer 6

Correct Answers:

Begin with questions that are less sensitive in nature

Rationale :

✳️ Building rapport is essential when discussing sensitive issues like suicidal ideation. ✳️ Starting with less threatening questions helps ease client anxiety and promotes trust. ✳️ This approach allows the nurse to gradually explore deeper concerns. ✳️ Direct but tactful questioning improves accuracy and client openness.

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Answer 7

Correct Answers:

Begin with questions that are less sensitive in nature

Rationale :

✳️ Building rapport is essential when discussing sensitive issues like suicidal ideation. ✳️ Starting with less threatening questions helps ease client anxiety and promotes trust. ✳️ This approach allows the nurse to gradually explore deeper concerns. ✳️ Direct but tactful questioning improves accuracy and client openness.

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Answer 8

Correct Answers:

A young woman who suddenly goes blind with no indication of organic pathology

Rationale :

🎀 Conversion disorder (functional neurological disorder) involves neurological symptoms inconsistent with medical findings.

🎀 Sudden blindness without a physiological basis is a classic example.

🎀The symptoms serve a psychological function and often appear after stress.

🎀 Nurses should validate the symptom while avoiding reinforcement of the dysfunction.

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Answer 9

Correct Answers:

Lorazepam 2 mg IM.

Rationale :

🔶 Lorazepam is a benzodiazepine and first-line agent for alcohol withdrawal and delirium tremens (DTs).

🔶 It reduces agitation, prevents seizures, and manages autonomic hyperactivity.

🔶 Prompt intervention with lorazepam can prevent worsening delirium and complications.

🔶 The medication should be administered as needed (PRN) during DT onset.

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Answer 10

Correct Answers:

Spend time sitting in silence with client.

Rationale :

🔷 Clients with depression often experience psychomotor retardation, which can delay their verbal responses.

🔷 Pressuring them to speak may increase anxiety and reduce trust.

🔷 Sitting silently conveys therapeutic presence and allows the client time to process thoughts.

🔷 This non-verbal support builds rapport and encourages future communication

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RN HESI Mental Health 2023

No.

1 :
A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The nurse also determine the client is homeless and is exhibiting suspiciousness. This client's plan of care should include what priority problem?

2 :
A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?

3 :
The nurse is performing intake interviews at a psychiatric clinic. A client with a known history of drug abuse reports having had a heart attack four years ago. Use of which substance places the client at highest risk for myocardial infarction?

4 :
The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?

5 :
The nurse documents that a client with schizophrenia is delusional. Which statement by the client confirms this assessmen

6 :
Which is the best approach for the nurse to use when interviewing a client about suicidal ideations?

7 :
Which is the best approach for the nurse to use when interviewing a client about suicidal ideations?

8 :
The charge nurse of the psychiatric unit observes clients in the day area. Which client is exhibiting symptoms of a conversion disorder.

10 :
When the nurse addresses questions to an adult client who is depressed, the client's responses are delayed. Which intervention should the nurse include in the client's plan of care?

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RN HESI Mental Health 2023

No.

1 : A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The nurse also determine the client is homeless and is exhibiting suspiciousness. This client's plan of care should include what priority problem?

2 : A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?

3 : The nurse is performing intake interviews at a psychiatric clinic. A client with a known history of drug abuse reports having had a heart attack four years ago. Use of which substance places the client at highest risk for myocardial infarction?

4 : The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?

5 : The nurse documents that a client with schizophrenia is delusional. Which statement by the client confirms this assessmen

6 : Which is the best approach for the nurse to use when interviewing a client about suicidal ideations?

7 : Which is the best approach for the nurse to use when interviewing a client about suicidal ideations?

8 : The charge nurse of the psychiatric unit observes clients in the day area. Which client is exhibiting symptoms of a conversion disorder.

10 : When the nurse addresses questions to an adult client who is depressed, the client's responses are delayed. Which intervention should the nurse include in the client's plan of care?

1 :
A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The nurse also determine the client is homeless and is exhibiting suspiciousness. This client's plan of care should include what priority problem?

2 :
A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?

3 :
The nurse is performing intake interviews at a psychiatric clinic. A client with a known history of drug abuse reports having had a heart attack four years ago. Use of which substance places the client at highest risk for myocardial infarction?

4 :
The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?

5 :
The nurse documents that a client with schizophrenia is delusional. Which statement by the client confirms this assessmen

6 :
Which is the best approach for the nurse to use when interviewing a client about suicidal ideations?

7 :
Which is the best approach for the nurse to use when interviewing a client about suicidal ideations?

8 :
The charge nurse of the psychiatric unit observes clients in the day area. Which client is exhibiting symptoms of a conversion disorder.

10 :
When the nurse addresses questions to an adult client who is depressed, the client's responses are delayed. Which intervention should the nurse include in the client's plan of care?