A male client with schizophrenia who is taking fluphenazine decanoate (Prolixin decanoate) is being discharged in the morning. A repeat dose of medication is scheduled for 20 days after discharge. The client tells the nurse that he is going on vacation in the Bahamas and will return in 18 days. Whi...
a male client with schizophrenia who is taking fluphenazine decanoate prolixin decanoate is being discharged in the morning a repeat dose of medication is sche
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Mental Health Practice HESI
1.
A male client with schizophrenia who is taking fluphenazine decanoate (Prolixin
decanoate) is being discharged in the morning. A repeat dose of medication is
scheduled for 20 days after discharge. The client tells the nurse that he is going on
vacation in the Bahamas and will return in 18 days. Which statement by the client
indicates a need for health teaching?
A) When I return from my tropical island vacation, I will go to the clinic to get my Prolixin
injection.
B) While I am on vacation and when I return, I will not eat or drink anything that contains
alcohol.
C) I will notify the healthcare provider if I have a sore throat or flu-like symptoms.
D) I will continue to take my benztropine mesylate (Cogentin) every day. answer-
Photosensitivity is a side effect of Prolixin and a vacation in the Bahamas (with its
tropical island climate) increases the client's chance of experiencing this side effect. He
should be instructed to avoid direct sun (A) and wear sunscreen. (B, C, and D) indicate
accurate knowledge. Alcohol acts synergistically with Prolixin (B). (C) lists signs of
agranulocytosis, which is also a side effect of Prolixin. In order to avoid extrapyramidal
symptoms (EPS), anticholinergic drugs, such as Cogentin, are often prescribed
prophylactically with Prolixin.
Correct Answer(s): A
2.
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. Vital signs are: temperature, 100° F,
pulse 100, and BP 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. answer- 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 (A) should
be addressed after giving the client Ativan for elevated vital signs secondary to alcohol
withdrawal. (C and D) can be addressed when immediate needs for safety are met.
Correct Answer(s): B
3.
The charge nurse is collaborating with the nursing staff about the plan of care for a
client who is very depressed. What is the most important intervention to implement
during the first 48 hours after the client's admission to the unit?
A) Monitor appetite and observe intake at meals.
B) Maintain safety in the client's milieu.
C) Provide ongoing, supportive contact.
,Mental Health Practice HESI
D) Encourage participation in activities. answer- The most important reason for closely
observing a depressed client immediately after admission is to maintain safety (B),
since suicide is a risk with depression. (A, C, and D) are all important interventions, but
safety is the priority.
Correct Answer(s): B
4.
A 38-year-old female client is admitted with a diagnosis of paranoid schizophrenia.
When her tray is brought to her, she refuses to eat and tells the nurse, "I know you are
trying to poison me with that food." Which response is most appropriate for the nurse to
make?
A) I'll leave your tray here. I am available if you need anything else.
B) You're not being poisoned. Why do you think someone is trying to poison you?
C) No one on this unit has ever died from poisoning. You're safe here.
D) I will talk to your healthcare provider about the possibility of changing your diet.
answer- (A) is the best choice cited. The nurse does not argue with the client nor
demand that she eat, but offers support by agreeing to "be there if needed", e.g., to
warm the food. (B and C) are arguing with the client's delusions, and (B) asks "why"
which is usually not a good question for a psychotic client. (D) has nothing to do with the
actual problem; i.e., the problem is not the diet (she thinks any food given to her is
poisoned.)
Correct Answer(s): A
5.
A client who is being treated with lithium carbonate for bipolar disorder develops
diarrhea, vomiting, and drowsiness. What action should the nurse take?
A) Notify the healthcare provider immediately and prepare for administration of an
antidote.
B) Notify the healthcare provider of the symptoms prior to the next administration of the
drug.
C) Record the symptoms as normal side effects and continue administration of the
prescribed dosage.
D) Hold the medication and refuse to administer additional amounts of the drug.
answer- Early side effects of lithium carbonate (occurring with serum lithium levels
below 2.0 mEq per liter) generally follow a progressive pattern beginning with diarrhea,
vomiting, drowsiness, and muscular weakness. At higher levels, ataxia, tinnitus, blurred
vision, and large dilute urine output may occur. (B) is the best choice. Although these
are expected symptoms, the healthcare provider should be notified prior to the next
administration of the drug. (A, C, and D) would not reflect good nursing judgment.
Correct Answer(s): B
6.
,Mental Health Practice HESI
The parents of a 14-year-old boy bring their son to the hospital. He is lethargic, but
responsive. The mother states, "I think he took some of my pain pills." During initial
assessment of the teenager, what information is most important for the nurse to obtain
from the parents?
A) If he has seemed depressed recently.
B) If a drug overdose has ever occurred before.
C) If he might have taken any other drugs.
D) If he has a desire to quit taking drugs. answer- Knowledge of all substances taken
(C) will guide further treatment, such as administration of antagonists, so obtaining this
information has the highest priority. (A and B) are also valuable in planning treatment.
(D) is not appropriate during the acute management of a drug overdose.
Correct Answer(s): C
7.
The wife of a male client recently diagnosed with schizophrenia asks the nurse, "What
exactly is schizophrenia? Is my husband all right?" Which response is best for the nurse
to provide to this family member?
A) It sounds like you're worried about your husband. Let's sit down and talk.
B) It is a chemical imbalance in the brain that causes disorganized thinking.
C) Your husband will be just fine if he takes his medications regularly.
D) I think you should talk to your husband's psychologist about this question. answer-
The nurse should answer the client's question with factual information and explain that
schizophrenia is a chemical imbalance in the brain (B). (A) is a therapeutic response but
does not answer the question, and may be an appropriate response after the nurse
answers the question asked. Although (C) is likely true to some degree, it is also true
that some clients continue to have disorganized thinking even with antipsychotic
medications. Referring the spouse to the psychologist (D) is avoiding the issue; the
nurse can and should answer the question.
Correct Answer(s): B
8.
The community health nurse talks to a male client who has bipolar disorder. The client
explains that he sleeps 4 to 5 hours a night and is working with his partner to start two
new businesses and build an empire. The client stopped taking his medications several
days ago. What nursing problem has the highest priority?
A) Excessive work activity.
B) Decreased need for sleep.
C) Medication management.
D) Inflated self-esteem. answer- The most important nursing problem is medication
management (C) because compliance with the medication regimen will help prevent
hospitalization. The client is also exhibiting signs of (A, B, and C); however, these
problems do not have the priority of medication management.
Correct Answer(s): C
, Mental Health Practice HESI
9.
At a support meeting of parents of a teenager with polysubstance dependency, a parent
states, "Each time my son tries to quit taking drugs, he gets so depressed that I'm afraid
he will commit suicide." The nurse's response should be based on which information?
A) Addiction is a chronic, incurable disease.
B) Tolerance to the effects of drugs causes feelings of depression.
C) Feelings of depression frequently lead to drug abuse and addiction.
D) Careful monitoring should be provided during withdrawal from the drugs. answer-
The priority is to teach the parents that their son will need monitoring and support during
withdrawal (D) to ensure that he does not attempt suicide. Although (A and C) are true,
they are not as relevant to the parent's expressed concern. There is no information to
support (B).
Correct Answer(s): D
10.
The nurse observes a female client with schizophrenia watching the news on TV. She
begins to laugh softly and says, "Yes, my love, I'll do it." When the nurse questions the
client about her comment she states, "The news commentator is my lover and he
speaks to me each evening. Only I can understand what he says." What is the best
response for the nurse to make?
A) What do you believe the news commentator said to you?
B) Let's watch news on a different television channel.
C) Does the news commentator have plans to harm you or others?
D) The news commentator is not talking to you. answer- It is imperative that the nurse
determine what the client believes she heard (A). The idea of reference may be to hurt
herself or someone else, and the main function of a psychiatric nurse is to maintain
safety. (B) is acceptable, but it is best to determine the client's beliefs. (C) is validating
the idea of reference, while (D) is challenging the client.
Correct Answer(s): A
11.
At the first meeting of a group of older adults at a daycare center for the elderly, the
nurse asks one of the members what kinds of things she would like to do with the group.
The older woman shrugs her shoulders and says, "You tell me, you're the leader." What
is the best response for the nurse to make?
A) Yes, I am the leader today. Would you like to be the leader tomorrow?
B) Yes, I will be leading this group. What would you like to accomplish during this time?
C) Yes, I have been assigned to be the leader of this group. I will be here for the next
six weeks.
D) Yes, I am the leader. You seem angry about not being the leader yourself. answer-
Anxiety over participation in a group and testing of the leader characteristically occur in
the initial phase of group dynamics. (B) provides information and focuses the group
back to defining its function. (A) is manipulative bargaining. Although (C) provides
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