Question

The nurse is initiating an interview with a client in the emergency department who presents with a fractured ulna and swollen, red lips and nose. The client's spouse is pacing outside the door of the examination room. Which action should the nurse take?

Answer 1

Correct Answers:

Ask the client to describe the history of the injuries.

Rationale :

🔸 The nurse must begin by assessing the client's version of events to identify possible abuse.

🔸 Collecting subjective data ensures client-centered care and safety assessment.

🔸 It also supports legal documentation and builds trust for potential IPV disclosure.

🔸 All other actions may be necessary later, but the first step is obtaining the injury history.

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Answer 2

Correct Answers:

Level of activity.

Rationale :

🔹 Increased activity may indicate emerging suicidal intent due to increased energy.

🔹 Comparing behavior pre- and post-medication helps detect early manic or activating side effects.

🔹 In adolescents, increased activity can signal risk-taking or impulsive behaviors.

🔹 It is critical to assess for both therapeutic response and potential danger.

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Answer 3

Correct Answers:

Helping clients identify areas of problem in their lives.

Rationale :

🔶 The working phase of group therapy focuses on problem-solving and behavioral change.

🔶 Clients begin applying insights and developing strategies to manage mental health issues.

🔶 This phase is where the most therapeutic work occurs with group support.

🔶 Nurse acts as a facilitator guiding members to identify and address core issues.

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Answer 4

Correct Answers:

Risk for self-directed violence related to impulsive behavior.

Rationale :

🟢 This client shows classic signs of mania, including impulsivity, weight loss, and sleep deprivation.

🟢 The most dangerous issue is risk for self-harm due to poor judgment.

🟢 These clients often engage in risky behaviors without forethought.

🟢 Prioritizing safety is key in initial mental health stabilization.

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Answer 5

Correct Answers:

Disturbed sensory perception.

Rationale :

🔴 The client's delusions indicate impaired interpretation of external reality.

🔴 Believing in a false marriage and sexual plotting suggests delusional thinking.

🔴 This falls under disturbed sensory perception (thought process-related).

🔴 Addressing hallucinations and delusions is essential before other nursing problems.

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Answer 6

Correct Answers:

Encourage activities that allow the client to exert control over his environment.

Rationale :

🔵 After multiple stressors and a suicide attempt, restoring a sense of control is therapeutic.

🔵 Structured, meaningful activities promote self-efficacy and recovery.

🔵 This reduces learned helplessness and supports emotional stabilization.

🔵 Avoiding or suppressing emotions can worsen depressive symptoms.

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Answer 7

Correct Answers:

Photographs

Rationale :

🟣 For clients experiencing IPV, photo documentation provides legal evidence.

🟣 It offers objective proof of injuries and protects both client and healthcare staff.

🟣 While emotional summaries are important, visuals support future interventions.

🟣 Documentation should be thorough, factual, and aligned with legal standards.

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Answer 8

Correct Answers:

Abnormal Involuntary Movement Scale (AIMS)

Rationale :

⚫ The client shows signs of tardive dyskinesia, a common side effect of long-term antipsychotic use.

⚫ AIMS is used to monitor for extrapyramidal symptoms (EPS).

⚫ Early identification allows for adjustment of medication to prevent progression.

⚫ Monitoring involuntary movements is critical in chronic psychotropic therapy.

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Answer 9

Correct Answers:

Take the medication each morning beginning 48 hours after your last drink of alcohol.

Rationale :

⚪ Disulfiram reacts violently with alcohol, so clients must abstain for at least 48 hours before starting.

⚪ It causes a disulfiram-alcohol reaction (nausea, vomiting, palpitations).

⚪ Timing is crucial for safe administration and therapeutic effect.

⚪ The client should be aware of hidden alcohol sources as well.

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Answer 10

Correct Answers:

Have the feelings associated with these events brought you to the clinic?

Rationale :

✴ This response explores the emotional impact of life events, a core therapeutic approach.

✴ It encourages self-reflection and helps guide further assessment.

✴ Asking about feelings builds rapport and insight, without being judgmental.

✴ It focuses on internal experiences, not external explanations.

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RN HESI Mental Health~C. H Exam.

No.

1 :
The nurse is initiating an interview with a client in the emergency department who presents with a fractured ulna and swollen, red lips and nose. The client's spouse is pacing outside the door of the examination room. Which action should the nurse take?

2 :
An adolescent who is exhibiting a depressed affect receives a prescription for an antidepressant drug. While the client is taking the antidepressant, which comparison of the client's behavior before and after taking the drug is most important for the nurse to obtain?

3 :
The nurse is leading a group on the inpatient psychiatric unit. Which approach should the nurse use during the working phase of group development?

5 :
A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?

7 :
The nurse completes an assessment of a client experiencing intimate partner violence (IPV). Which finding of the injuries should the nurse include in the documentation?

8 :
When assessing a client who takes psychotropic medications, the nurse notes that the client has uncontrollable hand movements and is excessively protruding the tongue. Which assessment in the client's record should the nurse review?

9 :
A client who is an alcoholic receives a prescription for disulfiram 500 mg PO daily. Which instruction should the nurse provide to this client?

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RN HESI Mental Health~C. H Exam.

No.

1 : The nurse is initiating an interview with a client in the emergency department who presents with a fractured ulna and swollen, red lips and nose. The client's spouse is pacing outside the door of the examination room. Which action should the nurse take?

2 : An adolescent who is exhibiting a depressed affect receives a prescription for an antidepressant drug. While the client is taking the antidepressant, which comparison of the client's behavior before and after taking the drug is most important for the nurse to obtain?

3 : The nurse is leading a group on the inpatient psychiatric unit. Which approach should the nurse use during the working phase of group development?

5 : A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?

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

8 : When assessing a client who takes psychotropic medications, the nurse notes that the client has uncontrollable hand movements and is excessively protruding the tongue. Which assessment in the client's record should the nurse review?

9 : A client who is an alcoholic receives a prescription for disulfiram 500 mg PO daily. Which instruction should the nurse provide to this client?

1 :
The nurse is initiating an interview with a client in the emergency department who presents with a fractured ulna and swollen, red lips and nose. The client's spouse is pacing outside the door of the examination room. Which action should the nurse take?

2 :
An adolescent who is exhibiting a depressed affect receives a prescription for an antidepressant drug. While the client is taking the antidepressant, which comparison of the client's behavior before and after taking the drug is most important for the nurse to obtain?

3 :
The nurse is leading a group on the inpatient psychiatric unit. Which approach should the nurse use during the working phase of group development?

5 :
A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?

7 :
The nurse completes an assessment of a client experiencing intimate partner violence (IPV). Which finding of the injuries should the nurse include in the documentation?

8 :
When assessing a client who takes psychotropic medications, the nurse notes that the client has uncontrollable hand movements and is excessively protruding the tongue. Which assessment in the client's record should the nurse review?

9 :
A client who is an alcoholic receives a prescription for disulfiram 500 mg PO daily. Which instruction should the nurse provide to this client?