after returning to work after a weekend off the nu
a client with dementia uses the defense mechanism
a husband states to the nurse that his wife is not
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Psych HESI
Psych HESI
1
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By: STARSHINESTUVIA • 11 months ago
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Psych
HESI
Questions
After
returning
to
work
after
a
weekend
off
the
nurse
gets
report
that
a
depressed
client
has
been
in
bed
all
weekend.
What
should
the
nurse
to
first?
-
ANSWER
Assist
the
client
out
of
bed
and
involve
in
activity .
A
client
with
dementia
uses
the
defense
mechanism
of
confabulation.
What
is
the
reasoning?
-
ANSWER
To
decrease
anxiety .
A
husband
states
to
the
nurse
that
his
wife
is
not
sleeping,
buying
impulsively ,
taking
last
minute
trips,
and
has
lost
22
pounds
one
month.
What
is
an
appropriate
nursing
dx?
-
ANSWER
Disturbed
thought
process.
A
nurse
is
explaining
a
fire
drill
routine
to
a
group
of
clients.
A
client
becomes
disruptive
and
continually
interrupts
the
group.
What
is
the
nurse's
best
response?
-
ANSWER
When
you
interrupt,
I
cannot
explain
what
to
do
to
the
group.
When
performing
a
MSE
on
a
client
which
assessment
intervention
would
best
assist
the
nurse?
-
ANSWER
Ask
the
client
to
interpret
the
proverb
a
stitch
in
time
saves
nine.
A
client
comes
in
after
being
in
a
car
accident
and
is
experiencing
alcohol
withdrawal,
magnesium
level
of
1.1,
cardiac
dysthrythmias.
What
would
you
give
first?
-
ANSWER
Magnesium.
A
woman
is
just
told
of
her
husband's
dx
of
terminal
cancer .
What
would
the
nurse
offer
for
the
spouse
(wife)?
-
ANSWER
How
would
you
like
to
be
involved
with
your
husband's
care?
A
nurse
is
to
remove
staples
from
an
abdominal
incision,
the
client
is
very
anxious.
What
is
the
most
important
intervention?
-
ANSWER
Attempt
to
distract
the
client
with
general
conversation.
A
man
who
was
stranded
on
the
roof
of
his
house
for
two
days
after
a
natural
disaster ,
months
later
...
-
ANSWER
Implement
anxiety
control
strategies.
A
man
dx
with
bipolar
disorder
states,
"I
don't
understand,
I
believe
in
God
and
have
not
done
anything
to
deserve
this".
What
is
the
nurse's
best
response?
-
ANSWER
You
didn't
do
anything
wrong.
You
have
a
chemical
imbalance
in
your
brain.
A
client
becomes
upset
when
the
nurse
he
requests
is
not
assigned
to
him,
what
is
the
nurse's
best
response?
-
ANSWER
Advise
the
client
that
nursing
assignments
are
not
based
on
client
requests.
A
client
needs
to
wash
her
hands
for
two
hours
before
able
to
go
on
with
her
morning.
She
doesn't
want
to
sit
on
the
chairs
in
the
dayroom
for
fear
of
getting
dirty.
What
is
this
mechanism?
-
ANSWER
Compulsion.
A
client
in
group
is
talking
about
her
prostitution,
the
nurse
asks
her
if
she
was
abused
by
her
parents.
She
states
"my
mother
ran
my
father
out
when
I
was
young".
What
defense
mechanism
was
used?
-
ANSWER
Repression.
A
woman
calls
the
crisis
hotline
and
says
she
has
a
loaded
gun
and
is
going
to
kill
herself.
To
maintain
patient
confidentiality
what
would
the
nurse
do?
-
ANSWER
Contact
the
person
the
client
chooses
to
go
to
the
home
and
remove
the
weapon.
A
client
with
anger
management
issues
uses
belt
making
and
bangs
the
leather
heavily .
What
defense
mechanisms
is
being
used?
-
ANSWER
Sublimation.
A
bipolar
client
comes
into
the
clinic
and
tells
the
nurse
that
the
next
time
she
sees
her
sister
I'm
going
to
kill
her.
What
should
the
nurse
do?
-
ANSWER
Inform
the
sister .
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