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HESI Exit Psych/Mental Health Saunders Question and Answers with explanations When a client is admitted to an inpatient mental health unit with the diagnosis of anorexia nervosa, a cognitive behavioral approach is used as part of the treatment plan. The nurse understands that which is the purpose of this approach?
- Providing a supportive environment
- Examining intrapsychic conflicts and past issues
- Emphasizing social interaction with clients who withdraw
- Helping the client to examine dysfunctional thoughts and beliefs - ✔4. Helping the client to examine dysfunctional thoughts and beliefs Rationale: Cognitive behavioral therapy is used to help the client identify and examine dysfunctional thoughts and to identify and examine values and beliefs that maintain these thoughts. The remaining options, while therapeutic in certain situations, are not the focus of cognitive behavioral therapy. The nurse understands that which best describes Gestalt therapy?
- It emphasizes self-expression, self-exploration, and self-awareness in the present.
- It promotes the individual's comfort in the group, which then transfers to other relationships.
- The therapist focuses on how irrational beliefs and thoughts contribute to psychological distress.
- The therapist's goal is to help others express their feelings toward one another during group sessions. - ✔1. It emphasizes self-expression, self-exploration, and self-awareness in the present. Rationale: Gestalt therapy emphasizes self-expression, self-exploration, and self- awareness in the present. The client and therapist focus on everyday problems and try to solve them. Interpersonal group therapy promotes the individual's comfort in the group, which then transfers to other relationships. In rational emotive therapy, the therapist focuses on how irrational beliefs and thoughts contribute to psychological distress. In Rogerian therapy, the therapist's goal is to help others express their feelings toward one another during group sessions. A client is preparing to attend a Gamblers Anonymous meeting for the first time. The nurse should tell the client that which is the first step in this 12- step program?
- Admitting to having a problem
- Substituting other activities for gambling
- Stating that the gambling will be stopped
- Discontinuing relationships with people who gamble - ✔1. Admitting to having a problem Rationale:
- Systematic desensitization - ✔4. Systematic desensitization Rationale: Systematic desensitization is a form of therapy used when the client is introduced to short periods of exposure to the phobic object while in a relaxed state. Exposure is gradually increased until the anxiety about or fear of the object or situation has ceased. Milieu management refers to providing a safe, therapeutic environment and is applicable to not just this scenario. The remaining options are incorrect since they do not involve the intervention described. A client is planning to attend Overeaters Anonymous. Which statement by the client indicates a need for additional information regarding this self-help group?
- "The leader is a nurse or psychiatrist."
- "The members provide support to each other."
- "People who have a similar problem are able to help others."
- "It is designed to serve people who have a common problem." - ✔1. "The leader is a nurse or psychiatrist." Rationale: The sponsor of a self-help group is an experienced member of the group. The nurse or psychiatrist may be asked by the group to serve as a resource, but would not be the leader of the group. The remaining options are characteristics of a self-help group.
What is the most appropriate nursing action to help manage a manic client who is monopolizing a group therapy session?
- Ask the client to leave the group for this session only.
- Refer the client to another group that includes other manic clients.
- Tell the client to stop monopolizing in a firm but compassionate manner.
- Thank the client for the input, but inform the client that now others need a chance to contribute. - ✔4. Thank the client for the input, but inform the client that now others need a chance to contribute. Rationale: If a client is monopolizing the group, the nurse must be direct and decisive. The best action is to thank the client and suggest that the client stop talking and try listening to others. Although telling the client to stop monopolizing in a firm but compassionate manner may be a direct response, the correct option is more specific and provides direction for the client. The remaining options are inappropriate since they are not directed towards helping the client in a therapeutic manner. Which type of therapeutic approach has the characteristic that all team members are seen as equally important in helping clients meet their goals?
- Milieu therapy
- Interpersonal therapy
- Behavior modification
- Rational emotive therapy - ✔1. Milieu therapy
- Move the client next to the nurse's station.
- Use an indirect light source and turn off the television.
- Keep the television and a soft light on during the night.
- Play soft music during the night, and maintain a well-lit room. - ✔2. Use an indirect light source and turn off the television. Rationale: Provision of a consistent daily routine and a low stimulating environment is important when a client is disoriented. Noise, including radio and television, may add to the confusion and disorientation. Moving the client next to the nurses' station may become necessary but is not the initial action. A client is admitted to the mental health unit with a diagnosis of depression. The nurse should develop a plan of care for the client that includes which intervention?
- Encouraging quiet reading and writing for the first few days
- Identification of physical activities that will provide exercise
- No socializing activities, until the client asks to participate in milieu
- A structured program of activities in which the client can participate - ✔4. A structured program of activities in which the client can participate Rationale: A client with depression often is withdrawn while experiencing difficulty concentrating, loss of interest or pleasure, low energy, fatigue, and feelings of worthlessness and poor self-esteem. The plan of care needs to provide successful experiences in a stimulating yet structured environment. The
remaining options are either too "restrictive" or offer little or no structure and stimulation. When planning the discharge of a client with chronic anxiety, the nurse directs the goals at promoting a safe environment at home. Which is the most appropriate maintenance goal?
- Suppressing feelings of anxiety
- Identifying anxiety-producing situations
- Continued contact with a crisis counselor
- Eliminating all anxiety from daily situations - ✔2. Identifying anxiety-producing situations Rationale: Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid a specific stimulus. Counselors will not be available for all anxiety-producing situations, and this option does not encourage the development of internal strengths. Suppressing feelings will not resolve anxiety. Elimination of all anxiety from life is impossible. A client is unwilling to go out of the house for fear of "making a fool of myself in public." Because of this fear, the client remains homebound. Based on these data, which mental health disorder is the client experiencing?
- Agoraphobia
- Social phobia
- Claustrophobia
inappropriate. This may agitate the client and escalate the client's behavior further. Barring the client from group sessions is also an inappropriate action because it violates the client's right to receive treatment and is a threatening action. A client is admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in a hit-and-run accident. When diagnostic testing cannot identify any organic reason why this client cannot see, a mental health consult is prescribed. Which condition will be the focus of this consult?
- Psychosis
- Repression
- Conversion disorder
- Dissociative disorder - ✔3. Conversion disorder Rationale: A conversion disorder is the alteration or loss of a physical function that cannot be explained by any known pathophysiological mechanism. A conversion disorder is thought to be an expression of a psychological need or conflict. In this situation, the client witnessed an accident that was so psychologically painful that the client became blind. Psychosis is a state in which a person's mental capacity to recognize reality, communicate, and relate to others is impaired, interfering with the person's ability to deal with life's demands. Repression is a coping mechanism in which unacceptable feelings are kept out of awareness. A dissociative disorder is a disturbance
or alteration in the normally integrative functions of identity, memory, or consciousness. A manic client begins to make sexual advance towards visitors in the dayroom. When the nurse firmly states that this is inappropriate and will not be allowed, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, which intervention should the nurse implement?
- Place the client in seclusion for 30 minutes.
- Tell the client that the behavior is inappropriate.
- Escort the client to their room, with the assistance of other staff.
- Tell the client that their telephone privileges are revoked for 24 hours. - ✔3. Escort the client to their room, with the assistance of other staff. Rationale: The client is at risk for injury to self and others and should be escorted out of the dayroom. Seclusion is premature in this situation. Telling the client that the behavior is inappropriate has already been attempted by the nurse. Denying privileges may increase the agitation that already exists in this client. Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply.
- Communicate expected behaviors to the client.
- Ensure that the client knows that they are not in charge of the nursing unit.
- Assist the staff in caring for the client in a controlled environment.
- Offer the client a less stimulating area to calm down in and gain control. - ✔1. Provide safety for the client and other clients on the unit. Rationale: Safety of the client and other clients is the priority. The correct option is the only one that addresses the safety needs of the client as well as those of the other clients. The nurse is preparing a client with a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client understands the instructions?
- "My medications aren't likely to make me anxious."
- "I'll go to support group and talk so that I don't hurt anyone."
- "It's not likely that I'll get anxious or hear things if I get enough sleep and eat well."
- "When I begin to hallucinate, I'll call my therapist and talk about what I should do." - ✔4. "When I begin to hallucinate, I'll call my therapist and talk about what I should do." Rationale: The risk for impulsive and aggressive behavior may increase if a client is receiving command hallucinations to harm self or others. If the client is experiencing a hallucination, the nurse should ask the client whether he or
she has intentions to hurt him- or herself or others. Talking about auditory hallucinations can interfere with subvocal muscular activity associated with a hallucination. The client statements in the remaining options will aid in wellness, but are not specific interventions for hallucinations, if they occur. The nurse is caring for a client diagnosed with catatonic stupor who is lying on the bed in a fetal position. What is the most appropriate nursing intervention?
- Ask direct questions to encourage talking.
- Leave the client alone so as to minimize external stimuli.
- Sit beside the client in silence with occasional open-ended questions.
- Take the client into the dayroom with other clients so that they can help watch him. - ✔3. Sit beside the client in silence with occasional open-ended questions. Rationale: Clients who are withdrawn may be immobile and mute and may require consistent, repeated approaches. Communication with withdrawn clients requires much patience from the nurse. Interventions include the establishment of interpersonal contact. The nurse facilitates communication with the client by sitting in silence, asking open-ended questions rather than direct questions, and pausing to provide opportunities for the client to respond. While overstimulation is not appropriate, there is no therapeutic value in ignoring the client. The client's safety is not the responsibility of other clients.
- Basketball - ✔2. Writing Rationale: Solitary activities that require a short attention span with mild physical exertion are the most appropriate activities for a client who is exhibiting aggressive behavior. Writing (journaling), walks with staff, and finger painting are activities that minimize stimuli and provide a constructive release for tension. The remaining options have a competitive element to them and should be avoided because they can stimulate aggression and increase psychomotor activity. The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action should the nurse take to plan appropriate nursing care?
- Ask the client why he started taking illegal drugs.
- Ask the client about the amount of drug use and its effect.
- Ask the client how long he thought that he could take drugs without someone finding out.
- Not ask any questions for fear that the client is in denial and will throw the nurse out of the home. - ✔1. Ask the client why he started taking illegal drugs. Rationale: Whenever the nurse carries out an assessment for a client who is dependent on drugs, it is best for the nurse to attempt to elicit information by being nonjudgmental and direct. Option 1 is incorrect because it is judgmental and
off-focus, and reflects the nurse's bias. Option 3 is incorrect because it is judgmental, insensitive, and aggressive, which is nontherapeutic. Option 4 is incorrect because it indicates passivity on the nurse's part and uses rationalization to avoid the therapeutic nursing intervention. Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply.
- Monitor vital signs.
- Maintain NPO status.
- Provide a safe environment.
- Address hallucinations therapeutically.
- Provide stimulation in the environment.
- Provide reality orientation as appropriate. - ✔1, 3, 4, 6 Rationale: When the client is experiencing withdrawal from alcohol, the priority for care is to prevent the client from harming self or others. The nurse would provide a low-stimulation environment to maintain the client in as calm a state as possible. The nurse would monitor the vital signs closely and report abnormal findings. The nurse would reorient the client to reality frequently and would address hallucinations therapeutically. Adequate nutritional and fluid intake need to be maintained. The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group if the nurse hears the wife make which statement?
the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. What action should the nurse take?
- Call the nursing supervisor.
- Call security to block all exit areas.
- Restrain the client until the health care provider (HCP) can be reached.
- Tell the client that the client cannot return to this hospital again if the client leaves now. - ✔1. Call the nursing supervisor. Rationale: Most health care facilities have documents that the client is asked to sign relating to the client's responsibilities when the client leaves against medical advice. The client should be asked to wait to speak to the HCP before leaving and to sign the "against medical advice" document before leaving. If the client refuses to do so, the nurse cannot hold the client against the client's will. Therefore, in this situation, the nurse should call the nursing supervisor. The nurse can be charged with false imprisonment if a client is made to believe wrongfully that he or she cannot leave the hospital. Restraining the client and calling security to block exits constitutes false imprisonment. All clients have a right to health care and cannot be told otherwise. The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings does the nurse expect to note? Select all that apply.
- Dental decay
- Moist oily skin
- Loss of tooth enamel
- Electrolyte imbalances
- Body weight well below ideal range - ✔1, 3, 4 Rationale: Clients with bulimia nervosa initially may not appear to be physically or emotionally ill. They are often at or slightly below ideal body weight. On further inspection, a client exhibits dental decay and loss of tooth enamel if the client has been inducing vomiting. Electrolyte imbalances are present. Dry, scaly skin (rather than moist, oily skin) is present. The nurse is caring for a female client who was admitted to the mental health unit recently for anorexia nervosa. The nurse enters the client's room and notes that the client is engaged in rigorous push-ups. Which nursing action is most appropriate?
- Interrupt the client and weigh her immediately.
- Interrupt the client and offer to take her for a walk.
- Allow the client to complete her exercise program.
- Tell the client that she is not allowed to exercise rigorously. - ✔2. Interrupt the client and offer to take her for a walk. Rationale:
