HESI RN Mental Health Exam

HESI RN Mental Health Exam

VERSION 12

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The nurse should expect the client who has Stage 4 Alzheimer’s disease to still have the ability to eat without assistance. Clients who have Alzheimer’s disease maintain this ability until Stage 7.

• The client independently manages personal finances.

The nurse should expect the client who has Stage 4 Alzheimer’s disease to have difficulty performing complex tasks, such as managing personal finances.

• The client has bladder incontinence.

The nurse should expect the client who has Stage 4 Alzheimer’s disease to be able to use the toilet independently. Clients who have Alzheimer’s disease maintain continence until Stage 6.

• The client is able to identify the names of family members.

The nurse should expect the client who has Stage 4 Alzheimer’s disease to recognize and identify family members. Clients who have Alzheimer’s disease maintain this ability until Stage 6.

• A nurse is caring for a client who reports that the television set in the room is really a two-way

radio and states, "voices are coming from the TV and everything we say in the room is being recorded." Which of the following responses should the nurse make?

• "What we say is not being recorded."

The nurse should avoid negating the client’s beliefs about the delusion. This response can promote a defensive client response and interfere with the development of trust in the nurse-client relationship.

• "Let's ignore the voices and talk about something else." 2 / 4

The nurse should ask the client directly about what the voices are saying to determine if there is a safety risk. The nurse should also avoid validating that the voices are real, which promotes the client’s beliefs about the delusion.

• "That must be very frightening."

The nurse should respond to the client’s delusion in a calm and empathetic manner. By acknowledging to the client that the delusion must be frightening, the nurse promotes the nurse-client relationship.

• "Why do you think the TV is a two-way radio?"

The nurse should avoid asking the client a "why" question, which promotes a defensive client response.

• A nurse is planning care for a newly admitted client who has bipolar disorder and is

experiencing acute mania. Which of the following client goals should the nurse identify as the priority?

• Practicing problem-solving skills

The nurse should encourage the client to practice problem-solving skills during the continuation phase of treatment; however, there is another intervention that is the priority during the acute phase of bipolar disorder.

• Understanding of medication regimen

The nurse should ensure that the client understands the medication regimen during the continuation phase of treatment; however, there is another intervention that is the priority during the acute phase of bipolar disorder.

• Identifying indications of relapse 3 / 4

The nurse should teach the client to recognize indications of relapse during the continuation phase of treatment; however, there is another intervention that is the priority during the acute phase of bipolar disorder.

• Maintaining adequate hydration

The nurse should identify that the priority goal is to prevent physical exhaustion,

maintain health, and meet nutritional and rest needs during the acute phase of the client’s manic episode. The nurse should consider Maslow’s hierarchy of needs, which includes five levels of priority when planning care for this client. The first level consists of physiological needs; the second level consists of safety and security needs; the third level consists of love and belonging needs; the fourth level consists of personal achievement and self-esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve and cope with life situations. When applying Maslow’s hierarchy of needs priority-setting framework the nurse should review physiological needs first.The nurse should then address the client’s needs by following the remaining four hierarchical levels. It is important, however, for the nurse to consider all contributing client factors, as higher levels of the pyramid can compete with those at the lower levels, depending on the specific client situation. The fourth level of Maslow’s hierarchy of needs includes usefulness, self-worth, and self-confidence in fulfilling self-esteem needs.

• A nurse is preparing to administer benzodiazepine to a client with Generalized Anxiety

Disorder. The nurse should tell the client to expect with of the following adverse reactions?

• Tinnitus

Tinnitus is not an adverse effect of benzodiazepines.

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