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MENTAL HESI 5
1. A male client is admitted to the mental health unit because he was feeling depressed
about the loss of his wife and job. The client has a history of alcohol dependency and
admits that he was drinking alcohol 12 hours ago. His temperature is 100.0 F, pulse is
100, and blood pressure is 142/100. The nurse plans to give the client lorazepam
(Ativan) based on which priority nursing diagnosis?
a. Risk for injury related to suicidal ideation.
b. Risk for injury related to alcohol detoxification.
c. Knowledge deficit related to ineffective coping.
d. Health seeking behaviors related to personal crisis.
The most important nursing diagnosis is related to alcohol detoxification (B) because the
client has elevated vital signs, a sign of alcohol detoxification. Maintaining client safety
related to suicidal ideation (A) should be addressed after giving the client Ativan for
elevated vital signs secondary to alcohol withdrawal. The client's knowledge deficit and
health seeking behaviors (C and D) can be addressed when immediate needs for safety
are met.
2. A nurse working in the emergency room of a children's hospital admits a child whose
injuries could have resulted from abuse. Which statement most accurately describes
the nurse's responsibility in cases of suspected child abuse?
a. Obtain objective data such as x-rays before reporting suspicions.
b. Confirm suspicions of abuse with the physician.
c. Report any case of suspected child abuse.
d. Document injuries to confirm suspected abuse.
It is the nurse's legal responsibility to report all suspected cases of child abuse (C), and
notifying the nurse manager or charge nurse starts the legal reporting process. (A, B,
and D) delay the first step in reporting the abuse.
3. A child is brought to the emergency room with a broken arm. Because of other
injuries, the nurse suspects the child may be a victim of abuse. When the nurse tries to
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give the child an injection, the child's mother becomes very loud and shouts, "I won't
leave my son! Don't you touch him! You'll hurt my child!" What is the best
interpretation of the mother's statements?
a. She is regressing to an earlier behavior pattern.
b. She is sublimating her anger.
c. She is projecting her feelings onto the nurse.
d. She is suppressing her fear.
Projection is attributing one's own thoughts, impulses, or behaviors onto another--it is
the mother who is probably harming the child and she is attributing her actions to the
nurse (C). The mother may be immature, but regression (A) is not the best description of
her behavior. Sublimation (B) is substituting a socially acceptable feeling for an
unacceptable one. These are not socially acceptable feelings. The mother may be
suppressing her fear (D) by displaying anger, but such an interpretation cannot be
concluded from the data presented.
4. A client, who is on a 30-day commitment to a drug rehabilitation unit, asks the nurse if
he can go for a walk on the grounds of the treatment center. When he is told that his
privileges do not include walking on the grounds, the client becomes verbally abusive.
Which approach should the nurse take?
a. Ask the staff to escort the client to his room.
b. Have the client ask his physician to change his privileges.
c. Remind the client of the importance of following the rules.
d. Disregard the client's inappropriate verbal outburst.
The client is trying to engage the nurse in a dispute. Ignoring the behavior (D) provides
no reinforcement for the inappropriate behavior. (A) is not necessary unless the client
becomes a physical threat to the nurse. It is inappropriate to delegate the situation to
the physician (B) and is not in keeping with good health team management. Consistent
limits must be established and enforced. (C) would subject the nurse to more verbal
abuse. The client could use any response as an excuse to attack the nurse once again.
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