Mental health Hesi Exam-2020 Middle age female with no previous mental illness and the family states that she is having paranoid thoughts, pt states: "I want to find out why people are stalking me".(ANS- Therapeutic response: "it sounds like this experience is frightening for you" Pt is mad at mom for turning him in and wants mom to bring belongings and does not want to talk to her. What action does the nurse need to take before the visit?(ANS- Discuss methods of clear communication Duty to warn question: Pt tells the nurse that he wants to kill his boss, nurse tells healthcare provider, healthcare provider tells his boss. What disciplinary action is needed? (ANS- None. The action was appropriate
Defense mechanism question: for projection
(ANS- "I am here because the police said I did something wrong" pt with stress admits to taking care of the ex-husband 's parents. Which defense mechanism is this?(ANS- Regression therapeutic Milieu: Pt had a recent suicide attempt after his wife offered divorce, lost his job, and his best friend moved away. What is the best nursing intervention to support therapeutic Milieu ? 1 / 2
(ANS- Encourage activities that will allow him to take control over his environment Interview noting taking question (ANS- arrange the setting and decrease any stimuli Prep from D/C from the psychic unit, what should the nurse include ?(ANS- Explore that pt's feelings regarding the discharge People in a group home and they are wiping feces on the wall. What is the nurse's highest priority?(ANS- Infection control Pt refuses to take medications and in defiance sits in the middle of the hallway floor.Best nursing action?(ANS- To move other clients to another room Nurse and client trade roles: nurse demonstrates bad behavior of the client. Why is this important?(ANS- Role play assists the client to recognize their own behavior Pt states, "I don't know, I just can't think". What is the best activity by the nurse?(ANS- Set daily goals Adolescent interrupts group to talk about pets during group therapy. Best nursing action?(ANS- Redirect him with a handout
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