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Homework answers / question archive / Georgia State University NURS 3980 HESI MENTAL HEALTH RN EXAM 1 1)The nurse is using the CAGE questionnaires as a screening tool for a client who is seeking help because his wife said he had a drinking problem

Georgia State University NURS 3980 HESI MENTAL HEALTH RN EXAM 1 1)The nurse is using the CAGE questionnaires as a screening tool for a client who is seeking help because his wife said he had a drinking problem

Nursing

Georgia State University

NURS 3980

HESI MENTAL HEALTH RN

EXAM 1

1)The nurse is using the CAGE questionnaires as a screening tool for a client who is seeking help because his wife said he had a drinking problem. What information should the nurse explore indepth with the client based on this screening tool?

A.            Consumption, liver enzyme, gastrointestinal complains and bleeding.

B.            Minimizes drinking frequently misses family events, guilt about drinking, and amount of daily intake.

C.            Cancer screening results, anger, gastritis, daily alcohol intake.

D.            Efforts to cut down, annoyance with questions, guilt, drinking as an “Eye-opener”.

(Cutting down, annoyance, guilt and eye-opener drinking are represented with the acronym of CAGE)

 

 

2.            A client who is admitted with a closed head injury after a gall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the nurse identify as the priority?

A.            Place in a side-lying position with head of bed elevated.

B.            Administer disulfram (Atabuse ) immediately

C.            Give lorezapam (Ativan)PRN for signs of withdrawal.

D.            Provide thiamine and folate supplements as prescribed.

 

3.            The nurse leading a group session of adolescent clients give the members handout about anger management. One of the male clients is fidgety, interrupts peers when they try to talk, and talks about his pets at home. What nursing action is best for the nurse to take?

A.            Give the client permission to leave and return in 10 minutes.

B.            Explore the client’s feeling about his pets and home life.

C.            Encourage his peers to help involve him in the activity.

D.            Redirect him by encouraging him to read from the handout.

 

4.            The nurse is preparing medications for a client with bipolar disorder and notices that the antipsychotic medication was discontinued several day ago. Which medication should also be discontinued?

A.            Alprazolam (Xanax)

 

B.            Benztropine (Cogentin)

C.            Magnesium (Milk of Magneisa)

D.            Lithium (Lathotbabs)

 

5.            A middle-aged adult with major depressive disorder suffer from psychomotor redardation, hypersomnia, and amotivation. Which intervention is like to be most effective in returning this client to a normal level of functioning?

A.            Encourage the client to exercise.

B.            Suggest that the client develop a list of pleasurable activities.

C.            Provide education on methods to enhance sleep.

D.            Teach the client to develop a plan for daily structured activities.

 

6.            A male client with a long history of alcohol dependency arrives in the Emergency department describing the feeling of bugs crawling on his body. His blood pressure is 170/102, pulse rate is 110 beats/ min, and his blood alcohol level is 0 mg/dl. Which prescription should the nurse administer?

A.            Haloperidol (Hadol)

B.            Thiamine (Vitamin B1) C. Lorazapam (Ativan)

D. Diphenhydramine (Benadryl)

 

7.            The nurse is teaching a client about the initiation of a prescribed abstinence therapy using disulfiram (Antabuse). What information should the client acknowledge understanding?

A.            Completely abstain from heroin or cocaine use.

B.            Attend monthly meetings of alcoholic anonymous.

C.            Remain alcohol free for 12 hours prior to the first dose.

D.            Admit to others that he is a substance abuser.

 

8.            A female client reports feeling hopeless and is unable to stop crying. She explains that she is worried about losing her job. Since the client’s husband recently lost his job she feels her employment is essential to the family’s survival. To evaluate the effectiveness of cognitive- behavioral techniques, which client outcomes should the nurse include in the plan of care?

A.            Relates insight into problematic relationships

B.            Demonstrates a healthy relationship with husband.

C.            Described how the family can resolve problem.

D.            Changes thought patterns related to problem solving.

 

9.            A female client engages in repeated checks of door and window locks, behavior that presents her from arriving on time and interferes with her ability to function effectively. What action should the nurse take?

 

A.            Discuss checking the time frequently

B.            Ask the client why she checks the locks

C.            Plan a list of activities to be carried out daily.

D.            Determine the type and size of the locks.

 

10.          A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. That intervention is best for the nurse to implement?

A.            avoid recognizing the behavior.

B.            Isolate the client from other clients.

C.            Administer a PRN sedative. D. Escort the client to his room.

 

11.          A young adult male is hospitalized due to depression and an attempted suicide attempt. The client reports that he lost his job and was angry with his employer for firing him when he took an overdose of pain medications. Which behavior best indicates to the nurse that his condition is improving?

A.            Initiates interactions with other clients.

B.            Describes verbally when he is angry

C.            Participates in a job search with a social worker.

D.            Denies plans to harm himself or others.

 

12.          The nurse is completing the admission assessment of an underweight adolescent who is admitted to a psychiatric unit with a diagnosis of depression. Which finding requires notification to the healthcare providers

A.            Body mass index of 21

B.            Potassium level of 2.9 mEq/dl

C.            WBC of 10,000 mm3

D.            Blood pressure of 110/70 mmHg.

 

13.          Following involvement in a motor vehicles collision, a middle-aged adult client is admitted to the hospital with multiple facial fractures, The client’s bold alcohol level is high on admission. Which PRN prescription should be administered if the client begin to exhibits signs and symptoms of delirium tremors (DT)?

A.            Hydromorphone (Dilaudid) 2mg IM

B.            Prochloperazine (Compazine) 5mg IM

C.            Chlopronmazine (Thorazine) 50 mg IM D. Lorazepam (Ativan) 2mg IM.

 

14.          A female client, who is wearing dirty clothes and has afoul body odor, comes to the clinic reporting feeling scared because she is being stalked. What action is most important for the nurse to take?

A.            Assure client that the healthcare provider will see her today.

 

B.            Recommend that the client talk with a social worker.

C.            Ask the client to describe why she is being stalked.

D.            Offer the client a safe place to relax before interviewing her.

 

15.          A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit’s day room. What action should the nurse implement first?

A.            Administer a PRN sedative.

B.            Sit in the chair next to the client.

C.            Escort the client to his room.

D.            Listen to what the client is saying.

 

16.          A teenager who has lost 20 pounds in the last three months is admitted to the hospital with hypotension and tachycardia. The client reports irregular menses and hair loss. Which intervention is most important for the nurse to include in the clients plans of care?

A.            Initiate caloric and nutritional therapy.

B.            Implement behavioral modification therapy.

C.            Evaluate the client for low self-esteem.

D.            Record daily weights and graft trend.

 

17.          The nurse is developing unit policies that will include nursing guidelines for maintaining a therapeutic milieu. Which interventions should be included when providing a therapeutic milieu in an inpatient setting?

A.            Opportunities to contribute to one’s treatment plan.

B.            One on one dialogue sessions with the therapist.

C.            Regularly scheduled unit activities for peer interaction.

D.            Home visits to reintergrate into the family.

 

18.          After receiving treatment for anorexia, a student asks the school nurse for permission to work in the school cafeteria as part of the school’s work study program. What action should the nurse take?

A.            Recommend assignment to the receptionist’s office.

B.            Suggest that the student work in the athletic department.

C.            Refer the student to a psychiatrist for further discussion.

D.            Determine the parent’s opinion of the work assignment

 

19.          A middle-aged female client with no previous psychiatric history is seen in the mental health clinic because her family describes her as having paranoid thoughts. On assessment, she tells the nurse “I want to find out why these people are stalking me” which response should the nurse provide?

A.            “It sounds like this experience is frightening for you”

B.            “What makes you think people are stalking you?’

C.            “I know you are frightened, but no one is stalking you”

 

D.            “Do you think someone is trying to harm you”

 

20.          A male veteran who recently returned from a war zone has post traumatic stress disorder (PTSD) and is admitted to the psychiatric ward because of admitted suicidal ideation. On admission, the client’s family informed the HCP that therapy sessions did not seem to be helping. Select only one intervention that as the highest priority?

A.            Administer paraxeitne 40 mg as prescribed.

B.            Develop a list of therapy programs. C. Remove all shaving equipment.

D. Determine if client has a suicide plan.

 

 

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