HESI RN Mental Health Exam
VERSION 5
The nurse is using the CAGE questionnaires as a screening tool for a client who is seeking help because his wife said he had a drinking problem. What information should the nurse explore indepth with the client based on this screening tool?
- Consumption, liver enzyme, gastrointestinal complains and
- Minimizes drinking frequently misses family events, guilt about
- Cancer screening results, anger, gastritis, daily alcohol intake.
- Efforts to cut down, annoyance with questions, guilt, drinking as an
bleeding.
drinking, and amount of daily intake.
“Eye-opener”.(Cutting down, annoyance, guilt and eye-opener drinking are represented with the acronym of CAGE)
A client who is admitted with a closed head injury after a gall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the nurse identify as the priority?
- Place in a side-lying position with head of bed elevated.
- Administer disulfram (Atabuse ) immediately
- Give lorezapam (Ativan)PRN for signs of withdrawal.
- Provide thiamine and folate supplements as prescribed.
The nurse leading a group session of adolescent clients give the members handout about anger management. One of the male clients is fidgety, interrupts peers when they try to talk, and talks about his pets at home. What nursing action is best for the nurse to take?
- Give the client permission to leave and return in 10 minutes.
- Explore the client’s feeling about his pets and home life.
- Encourage his peers to help involve him in the activity.
- Redirect him by encouraging him to read from the handout.
The nurse is preparing medications for a client with bipolar disorder and notices that the antipsychotic medication was discontinued several day ago. Which medication should also be discontinued?
- Alprazolam (Xanax) 1 / 2
- Benztropine (Cogentin)
- Magnesium (Milk of Magneisa)
- Lithium (Lathotbabs)
A middle-aged adult with major depressive disorder suffer from psychomotor redardation, hypersomnia, and amotivation. Which intervention is like to be most effective in returning this client to a normal level of functioning?
- Encourage the client to exercise.
- Suggest that the client develop a list of pleasurable activities.
- Provide education on methods to enhance sleep.
- Teach the client to develop a plan for daily structured activities.
A male client with a long history of alcohol dependency arrives in the Emergency department describing the feeling of bugs crawling on his body. His blood pressure is 170/102, pulse rate is 110 beats/ min, and his blood alcohol level is 0 mg/dl. Which prescription should the nurse administer?
- Haloperidol (Hadol)
- Thiamine (Vitamin B1)
- Lorazapam (Ativan)
- Diphenhydramine (Benadryl)
The nurse is teaching a client about the initiation of a prescribed abstinence therapy using disulfiram (Antabuse). What information should the client acknowledge understanding?
- Completely abstain from heroin or cocaine use.
- Attend monthly meetings of alcoholic anonymous.
- Remain alcohol free for 12 hours prior to the first dose.
- Admit to others that he is a substance abuser.
A female client reports feeling hopeless and is unable to stop crying.She explains that she is worried about losing her job. Since the client’s husband recently lost his job she feels her employment is essential to the family’s survival. To evaluate the effectiveness of cognitive- behavioral techniques, which client outcomes should the nurse include in the plan of care?
- Relates insight into problematic relationships
- Demonstrates a healthy relationship with husband.
- Described how the family can resolve problem.
- Changes thought patterns related to problem solving.
- / 2
A female client engages in repeated checks of door and window locks, behavior that presents her from arriving on time and interferes with her ability to function effectively. What action should the nurse take?