The nurse is caring for an adult male client with catatonic schizophrenia who is mute and motionless. What is the priority nursing problem?
A. Impaired mobility.
B. Ineffective individual coping.
C. Impaired verbal communication.
D. High risk for fluid and electrolyte imbalance. -answer...
the nurse is caring for an adult male client with catatonic schizophrenia who is mute and motionless what is the priority nursing problem
psychiatricmental health assignment exam hesi practice exam
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Psychiatric/Mental Health Assignment
Exam Hesi Practice
The nurse is caring for an adult male client with catatonic schizophrenia who is mute
and motionless. What is the priority nursing problem?
A. Impaired mobility.
B. Ineffective individual coping.
C. Impaired verbal communication.
D. High risk for fluid and electrolyte imbalance. -answers ANS: D. High risk for fluid and
electrolyte imbalance.
Maintaining physiological stability by first addressing basic physiological needs is the
priority. A client who is in a catatonic or stuporous state is at risk for malnutrition and
dehydration. Fluid and electrolyte imbalance is the priority nursing problem for this client
at this time. The other problems are not life-threatening.
A female client comes to an outpatient therapy appointment intoxicated. The spouse
tells the nurse, "There wasn't anything I could do to stop her drinking this morning."
What intervention should the nurse take at this time?
A. Arrange for emergency admission to a detoxification unit.
B. Talk to the spouse about strategies to limit the client's drinking.
C. Have the client admitted to the inpatient psychiatric unit.
D. Tell the client that therapy cannot take place while she is intoxicated. -answers ANS:
D. Tell the client that therapy cannot take place while she is intoxicated.
Therapy sessions are designed to confront the issues that the client with alcohol
dependence may be experiencing. If the client presents inebriated, a therapeutic and
confrontational meeting cannot occur because the client's judgment is altered. The other
interventions are not necessary.
Which action is most important for the nurse to implement during the initial interview for
a client who is admitted to the mental health unit?
A. Establish rapport in each phase of the nurse-client relationship.
B. Determine the client's ability to communicate effectively.
C. Reflect on previous psychiatric interviews the nurse has performed.
,Psychiatric/Mental Health Assignment
Exam Hesi Practice
D. Ensure data is collected and recorded in a systematic sequence. -answers ANS: A.
Establish rapport in each phase of the nurse-client relationship.
A client with whom the nurse establishes rapport during the initial interview and in each
phase of the nurse-client relationship feels understood by the nurse and is more likely to
cooperate and provide feedback during the admission process. The other actions not
always needed to establish rapport or maintain the therapeutic self in a therapeutic
relationship.
The nurse is planning the care for a client based on the psychoanalytical model. Which
intervention should the nurse include in the plan of care?
A. Emphasize the client's strengths and assets.
B. Teach the importance of medication compliance.
C. Offer the client psychoeducational materials to read.
D. Focus on the client's positive or negative feelings toward the nurse. -answers ANS:
D. Focus on the client's positive or negative feelings toward the nurse.
Interactions and interventions that focus on the client's positive or negative feelings
toward the nurse are based on the psychoanalytical model of mental health care. The
other interventions are not associated with the psychoanalytical model.
A client on the mental health unit reports concerns about weight gain as a result of
taking divalproex (Depakote) and requests assistance to fill out a menu. The nurse
should initiate a referral to which healthcare team member?
A. Occupational therapist.
B. Recreational therapist.
C. Dietician.
D. Physician. -answers ANS: C. Dietician.
The nurse should ask for a referral to the dietician who can assist the client with meal
planning for weight reduction. The other members of the healthcare team do not give
guidance about meal planning.
Which client should the nurse identify as the highest risk for the onset of stress-related
problems?
, Psychiatric/Mental Health Assignment
Exam Hesi Practice
A. A man whose new business is growing slowly, who plans to adopt a child with his
wife, and says, "I think I'm in control of my destiny."
B. A woman who is graduating from college, getting married in one month, and states,
"I'm anticipating the changes these events will make in my life."
C. A client who is passed over for promotion, quits a job to start a new business, and
states, "This is just one of a series of challenges I've faced in my life."
D. A person whose father died three months ago, who is losing a job due to company
downsizing, and states, "Living with loss and the threat of loss makes me feel helpless."
-answers ANS: D. A person whose father died three months ago, who is losing a job
due to company downsizing, and states, "Living with loss and the threat of loss makes
me feel helpless."
A client who is dealing with two stressful life events and expresses a cognitive appraisal
of loss and helplessness is at the highest risk for a stress-related health problem. The
other persons are coping with change using healthy strategies.
An older client is admitted to a psychiatric hospital with the diagnosis, "Major
depression, single episode." Which laboratory value is most important for the nurse to
report to the healthcare provider immediately?
A. Increased serum creatinine level.
B. Positive rapid plasma reagin (RPR).
C. Increased thyroid stimulating hormone (TSH).
D. Elevated serum calcium level. -answers ANS: C. Increased thyroid stimulating
hormone (TSH).
The healthcare provider should be notified of TSH levels immediately. An increased
TSH suggests a low thyroxine level because TSH is being secreted to stimulate
thyroxine production, which is the pathophysiology of hypothyroidism that may present
as depression. The other results should be evaluated but do not have the priority
relative to the admission diagnosis.
A female client with bipolar disorder, manic phase, is planning weekend activities with
the other clients on the unit. The client interrupts the group, insists that they change
their plans to a disco party, and begins to curse loudly when the group refuses to
change the plans. Which intervention should the nurse implement?
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