HESI Mental Health

Correct Answer: Establish a patent airway

Explanation:

The priority intervention for a client who is unresponsive with bradypnea (slow breathing) and pinpoint pupils—classic signs of opioid overdose—is to establish a patent airway to ensure adequate oxygenation. Opioid overdose can cause respiratory depression, which is life-threatening if the airway is not clear and the client is not receiving sufficient oxygen. Without a patent airway, further assessments or interventions will be ineffective. Airway, Breathing, Circulation (ABC) guidelines dictate that maintaining an open airway takes precedence in emergencies where respiratory compromise is present. Once the airway is secure, other actions, such as assessing vital signs and administering medications like naloxone, can follow.

Why Other Options are Wrong:

Determine blood pressure and heart rate

While monitoring vital signs is important, it is secondary to ensuring airway patency. If the client cannot breathe effectively, measuring blood pressure and heart rate does not resolve the immediate life-threatening issue of respiratory depression. Airway management must occur first to prevent hypoxia and further deterioration.

Obtain vascular access with large bore catheter

Although vascular access is required to administer life-saving medications like naloxone, it should not precede airway management. Establishing IV access takes time and does not address the most urgent issue—oxygen deprivation due to compromised airway. If the airway is not managed promptly, the client may deteriorate into respiratory or cardiac arrest before medications can be administered.

Perform a Glasgow Coma Scale (GCS) assessment

The GCS provides useful information about the client's level of consciousness but is not appropriate as a first step in this scenario. Assessing neurological status does not directly address the client's critical need for oxygenation. Delaying airway management to perform a GCS assessment could lead to worsening hypoxia and permanent damage. Prioritizing airway ensures that the brain and other vital organs receive oxygen, which is essential before evaluating neurological function.

Correct Answer: Allow the client to rest and sleep.

Explanation:

Sleep deprivation can significantly worsen depressive symptoms such as irritability, hopelessness, cognitive impairment, and suicidal ideation. For a homeless client who has only had four hours of sleep in two days, allowing rest is a critical first step. Restful sleep aids in emotional regulation, mental clarity, and physiological recovery. In psychiatric care, addressing these immediate physical needs is essential before attempting more complex therapeutic interventions. This approach aligns with Maslow’s Hierarchy of Needs, where physiological needs like sleep must be met before psychological or self-fulfillment needs can be addressed.

Why Other Options Are Wrong:

Ensure client attends groups addressing coping skills for dealing with depression:

Although group therapy is helpful for managing depression, it is not an immediate priority for a sleep-deprived client. Forcing participation in group activities may worsen emotional and physical exhaustion, making it counterproductive and potentially distressing. The client must first achieve physical stability before they can meaningfully engage in group interventions.

Begin planning for the client’s discharge:

Discharge planning is a necessary component of care but should not occur when the client is physically and emotionally unstable. The client’s sleep deprivation suggests they are in an acute phase of distress, and planning for discharge at this point may lead to poor outcomes or a higher risk of readmission. Stabilizing the client’s basic needs should come first.

Encourage verbalization of feelings:

While talking about feelings is a core aspect of depression treatment, it requires a minimum level of emotional and cognitive readiness. A severely sleep-deprived client may be unable to express thoughts coherently, and pushing for emotional expression at this stage could lead to frustration or agitation. Prioritizing rest ensures the client will be in a better state to explore their feelings later.

Correct Answer: Offer strategies the spouse can use to provide comfort to the client.

Explanation

When a spouse expresses helplessness and hopelessness during a loved one's terminal illness, it is crucial to offer them practical strategies to stay engaged in the care process. These strategies might include providing physical comfort, such as holding the client’s hand or offering soothing words, or helping with personal care. Empowering the spouse in this way can reduce their sense of helplessness and emotional isolation, helping them feel more involved and purposeful during an incredibly difficult time. This approach strengthens the emotional bond between the client and their spouse, which is beneficial for both the caregiver’s well-being and the client’s comfort.

Why the other options are wrong

Suggest that the spouse go home for a while and get some sleep

Although rest is important for caregivers, suggesting that the spouse leave the client may inadvertently intensify feelings of guilt and helplessness. When a loved one is near death, the fear of missing critical moments can overwhelm the spouse, and sending them away may be perceived as dismissive or minimizing their emotional needs. It is typically better to encourage the spouse to remain involved rather than suggesting separation.

Explain that the staff will strive to keep the client comfortable

While it is important to reassure the spouse about the physical care the client will receive, this response does not address the spouse’s emotional distress or the helplessness they may feel. It is essential to recognize and validate the spouse’s emotional state by involving them in the caregiving process, which fosters emotional connection and purpose. A purely practical response without emotional support could leave the spouse feeling distanced from the process.

Offer comfort that healing can happen at any point in time

This statement is inappropriate in the context of a terminal illness, as it offers false hope that may not align with the reality of the situation. It can invalidate the spouse’s grief and emotional pain, making them feel misunderstood. A more helpful approach would be to acknowledge the gravity of the situation while providing emotional and practical support for the spouse’s coping process.

Summary:

The most compassionate and effective response is to offer the spouse practical strategies to comfort the client, which helps them feel involved and supported during the terminal phase. This approach minimizes feelings of helplessness and allows the spouse to maintain a sense of purpose. Other responses either distance the spouse emotionally, offer unrealistic hope, or focus solely on physical care without addressing emotional needs.

Correct Answer: Encourage the spouse to share their feelings.

Explanation

Encourage the spouse to share their feelings:

This is the most therapeutic and supportive action a nurse can take when someone is expressing anticipatory grief. Grief is a deeply emotional process, and individuals need space to express their emotions in order to begin healing. Encouraging the spouse to talk about their feelings demonstrates empathy, creates a safe environment, and allows the nurse to provide support through active listening. It validates the spouse’s experience and helps prevent emotional isolation, which is critical in the early stages of grief.

Why the other options are wrong

Offer reassurance that the spouse is not alone

Although this may seem compassionate, offering reassurance too early can come off as dismissive. It may shut down meaningful conversation by implying that the person's feelings are not serious or warranted. The spouse’s statement shows vulnerability, and they first need to feel heard and validated, not reassured.

Explain that alternative treatment options may be helpful

This shifts the focus away from the spouse’s emotional needs and onto clinical decisions. When someone is expressing grief, introducing treatment options may seem like denial of the severity of the situation. It can provide false hope and is not therapeutic in an emotionally charged moment.

Remind the spouse that the client may still live a long time

This response minimizes the spouse’s emotions and avoids addressing their pain. It can create a barrier between the nurse and the spouse by suggesting their concerns are overblown or unnecessary. Instead of comfort, it may cause frustration and make the spouse feel unheard or misunderstood.

Summary:

The most appropriate nursing action when a spouse is experiencing anticipatory grief is to encourage open emotional expression. Listening attentively and validating feelings helps provide support, foster trust, and facilitate healthy grieving.

Correct Answer: Give a PRN dose of chlordiazepoxide.

Explanation

The client is showing early signs of alcohol withdrawal, such as tremors and incoherence, which can rapidly progress to seizures or delirium tremens without prompt treatment. Chlordiazepoxide is a long-acting benzodiazepine commonly used in alcohol detoxification because it suppresses central nervous system excitability and helps prevent severe complications. Administering the PRN dose addresses the client’s immediate needs and prevents further clinical deterioration.

Why the other options are wrong

Notify the healthcare provider of the client's symptoms

While communication with the healthcare provider is important, a standing PRN prescription for withdrawal symptoms allows the nurse to act immediately. Waiting to notify the provider delays critical intervention during a period when rapid symptom escalation can occur, potentially putting the client at risk.

Decrease the client's environmental stimuli

Minimizing environmental stimuli can support comfort but is not sufficient to manage physiological symptoms of alcohol withdrawal. It may help reduce agitation, but without medication, the client remains at risk for seizures, hallucinations, or delirium tremens, making this a secondary intervention.

Encourage the client to attend Alcoholics Anonymous

Discussing long-term recovery strategies like AA participation is not appropriate when the client is in the acute withdrawal phase. The client is currently incoherent and symptomatic, requiring immediate medical stabilization before they are capable of engaging in therapeutic discussions about sobriety.

Summary:

The most urgent and effective response to alcohol withdrawal symptoms is administering a PRN dose of chlordiazepoxide, which treats the condition directly and prevents life-threatening complications. Other options either delay treatment or are better suited for later stages of care.

Correct Answer: "Regardless of the client's condition, all nurses have the duty to respect client rights"

Explanation

This statement reflects the nurse’s ethical and professional responsibility to uphold and advocate for client rights under all circumstances. It conveys that a nurse's duty to protect and honor the rights of the client—such as autonomy, dignity, informed consent, and confidentiality—does not depend on the client’s physical, mental, or emotional condition. This highlights the universal and non-negotiable nature of respecting client rights as part of holistic, client-centered care.

Why other options are wrong

"Autonomy is the fundamental right of each and every client"

While this statement is true, it narrows the focus to just one aspect of client rights. Nurses are responsible for protecting not only autonomy but also other rights such as privacy, informed consent, and access to care. The nurse’s role involves a broader commitment than just respecting autonomy alone.

"A client's rights are guaranteed by both state and federal laws"

This is a factual statement regarding the legal basis of client rights, but it does not address the nurse’s personal or professional responsibility in upholding these rights. A nurse must actively ensure that client rights are respected through their actions, beyond just acknowledging the legal framework.

"Being respectful and concerned will ensure that I'm attentive to my client's rights"

Although respectful and empathetic behavior is important, this statement lacks specificity. Respect and concern do not automatically translate to advocacy or full protection of client rights. Nurses need to be actively informed and intentional in their actions to protect those rights, regardless of how respectful their demeanor may be.

Correct Answer: Take daily for greatest effectiveness.

Explanation:

Disulfiram is an alcohol deterrent that works by inhibiting the enzyme aldehyde dehydrogenase, which leads to the accumulation of acetaldehyde when alcohol is consumed. This causes unpleasant symptoms like nausea, vomiting, and palpitations, making the idea of drinking alcohol undesirable. To ensure continuous aversion to alcohol, the medication must be taken daily. This consistent use is key to maintaining therapeutic levels in the body and reinforcing abstinence.

Why the Other Options Are Wrong:

Administer when there is a craving for alcohol:

Disulfiram is not designed to curb alcohol cravings directly. It works by creating a physical deterrent to alcohol use. Naltrexone is a better option for reducing alcohol cravings, as it blocks the euphoric effects of alcohol consumption.

Monitor blood tests after each administration:

Routine blood tests are not required after each dose of disulfiram. Monitoring liver function should be done periodically, typically at the start of therapy and every six months, due to the potential for hepatotoxicity, but not after every dose.

Continue use for a maximum of 10 days:

Disulfiram is typically used long-term, not just for a short period of 10 days. It is part of a comprehensive alcohol cessation plan and can be prescribed for months or years to maintain abstinence. A 10-day course would not provide the sustained effect necessary for ongoing sobriety.

Summary:

For disulfiram to be effective in supporting alcohol abstinence, it must be taken daily. This consistent medication regimen ensures therapeutic levels, promotes continuous aversion to alcohol, and supports long-term sobriety. Disulfiram is not intended for on-demand use, nor does it require frequent blood tests after each dose. It is also not limited to a short 10-day course.

The correct answer is: Refusal to address nutritional needs.

Explanation:

In clients with depression, one of the most immediate and potentially life-threatening concerns is ensuring that basic physiological needs, such as nutrition and hydration, are met. If a client refuses meals and is not taking in adequate nutrition, they can become malnourished, which can negatively affect their physical health and exacerbate depressive symptoms. Proper nutrition is essential for both physical and mental well-being, so addressing the refusal to eat is the highest priority in this scenario.

Why the Other Choices Are Incorrect:

Loss of interest in diversional activity: While loss of interest in activities (anhedonia) is a common symptom of depression, it does not pose an immediate physical threat like the refusal of meals does. Although it is important to help the client re-engage in activities, ensuring that their nutritional needs are met takes precedence.

Social isolation: Social isolation is another common issue for clients with depression. However, the refusal to engage socially is not as urgent a concern as ensuring proper nutrition and preventing physical harm from lack of food. Addressing social isolation may be addressed later once basic physiological needs are met.

Low self-esteem: Low self-esteem is often a key feature of depression, but again, addressing immediate physiological needs, such as nutrition, takes priority. While low self-esteem can be addressed over time through therapy and support, it is not as urgent as preventing malnutrition and its associated complications.

Summary:

The greatest priority for this client is to address the refusal to eat, as it poses a direct threat to their physical health and can worsen their depressive symptoms. Ensuring adequate nutrition is essential in the treatment of depression and helps to support the client's overall recovery. Once nutritional needs are addressed, the nurse can focus on other issues such as social isolation, loss of interest in activities, and low self-esteem.

The correct answer is:

A. Keep client NPO after midnight.

Explanation:

Electroconvulsive therapy (ECT) requires that the client be NPO (nothing by mouth) for a certain period before the procedure, typically for at least 6-8 hours. This is necessary to reduce the risk of aspiration during the procedure, as ECT involves the use of anesthesia. The client is put under general anesthesia for the treatment, and if the stomach contains food or liquid, there is a risk of vomiting and aspiration into the lungs, which can cause serious complications. Therefore, the RN should ensure the client remains NPO after midnight on the evening before the scheduled ECT.

Why the Other Choices Are Incorrect:

B. Hold all bedtime meds:

This is not a standard procedure before ECT. Some medications may need to be adjusted or withheld (especially if they affect the central nervous system or the ability to manage anesthesia), but this is typically determined by the healthcare provider. Therefore, the RN should not automatically hold all bedtime medications unless specifically instructed to do so by the healthcare provider.

C. Implement elopement precautions:

Elopement precautions (steps to prevent the client from leaving the facility without authorization) are not typically required for clients scheduled for ECT. These precautions may be used for clients who are at risk of harming themselves or others, or those with a history of elopement, but they are not a standard intervention for ECT. The focus in the evening before ECT is on preparing the client safely for the procedure, including ensuring they are NPO.

D. Give the client an enema at bedtime:

An enema is not typically indicated prior to ECT unless specifically ordered by the healthcare provider for another reason (such as constipation). There is no routine need for an enema before ECT, and this would not be an appropriate action unless there is a clinical reason for it.

Summary:

The most important intervention for the RN to implement the evening before a scheduled ECT is to keep the client NPO after midnight. This helps reduce the risk of aspiration during the procedure. Other interventions such as holding medications or implementing elopement precautions are not routine for ECT preparation unless specified by the healthcare provider.