HESI Mental Health

The correct answer is: Benztropine (Cogentin).

Explanation:

Benztropine is an anticholinergic medication often prescribed to prevent or treat extrapyramidal symptoms (EPS) caused by antipsychotic medications. Since EPS is a side effect of antipsychotic drugs, discontinuing the antipsychotic means there is no longer a need for benztropine. Continuing benztropine without the antipsychotic increases the risk of anticholinergic toxicity (e.g., dry mouth, constipation, urinary retention, blurred vision, confusion).

Why the other options are incorrect:

Lithium (Lithotabs):

Lithium is a mood stabilizer that is independent of antipsychotic medications. It is used long-term to manage bipolar disorder and should not be discontinued without a specific clinical reason. Stopping lithium abruptly can cause mood destabilization or rebound mania.

Alprazolam (Xanax):

Alprazolam is a benzodiazepine used to treat anxiety. It is not related to antipsychotic medications and does not need to be discontinued. It is usually prescribed for short-term anxiety management in clients with bipolar disorder.

Magnesium (Milk of Magnesia):

Magnesium is a n over-the-counter laxative and has no connection to a ntipsychotic or mood-stabilizing medications. It can be continued as needed without impacting the client’s psychiatric treatment.

Summary:

The correct answer is Benztropine (Cogentin) because it is used to treat side effects caused by antipsychotics. Once the antipsychotic is discontinued, benztropine is no longer necessary and could cause adverse effects if continued. Lithium, alprazolam, and magnesium are not directly impacted by discontinuing antipsychotics and should generally be continued unless other issues arise.

Correct Answer: Instruct the client that it is important to reduce the dose of the medication gradually.

Explanation

Temazepam, being a benzodiazepine, should not be discontinued abruptly because it can lead to withdrawal symptoms such as anxiety, agitation, seizures, and rebound insomnia. A gradual reduction in the dose under the guidance of a healthcare provider helps to minimize these withdrawal effects. It also ensures a safer transition for the client and prevents severe complications associated with abrupt discontinuation.

Why the other options are wrong

Discuss with the client that there may be a need for additional sleep if the feeling of fatigue is present the next day

While fatigue or drowsiness can occur with temazepam use, this response does not address the primary concern of safely discontinuing the medication. It also disregards the risks of sudden discontinuation, which could lead to withdrawal symptoms.

Encourage the client to obtain a prescription for a benzodiazepine antagonist

Benzodiazepine antagonists, such as flumazenil, are used in emergency overdose situations and are not appropriate for discontinuing the medication. Administering an antagonist in this context could trigger withdrawal symptoms or seizures in a person who has been regularly using the medication.

Advise the client to stop taking the medication immediately

Abruptly stopping temazepam is dangerous due to the risk of withdrawal symptoms, including rebound insomnia and seizures. Gradual tapering of the dose is the recommended method to safely discontinue the medication.

Summary:

The best approach to discontinuing temazepam is a gradual reduction in dosage, which prevents withdrawal symptoms and ensures safety. Other options either ignore the risks of abrupt cessation or suggest inappropriate measures for managing the situation.

Correct Answer: Suggest having wine with dinner so it is consumed 3 hours before bedtime.

Explanation

Consuming alcohol close to bedtime can exacerbate obstructive sleep apnea syndrome (OSAS) by relaxing the throat muscles, increasing the likelihood of airway obstruction during sleep. By recommending that the client have wine with dinner, at least 3 hours before bedtime, the nurse helps to mitigate this risk. This timing reduces the impact alcohol has on sleep quality, while still respecting the client’s preference for drinking wine. It is a balanced approach that helps manage OSAS symptoms effectively.

Why other options are wrong

Confirm that a glass of wine at bedtime can help promote relaxation and sleep:

While alcohol might initially make the client feel drowsy, it disrupts the sleep cycle by increasing nighttime awakenings and reducing rapid eye movement (REM) sleep. For individuals with OSAS, alcohol increases the risk of apneic episodes, worsening their condition. This advice could be harmful by encouraging alcohol consumption too close to bedtime.

Offer to contact the healthcare provider about a prescription for a sleeping aid:

This option is inappropriate because sedatives or sleeping aids can depress the central nervous system, causing further muscle relaxation. This could worsen OSAS by increasing the risk of airway obstruction. Non-pharmacological strategies, like adjusting alcohol consumption and sleep hygiene, are preferred for managing OSAS.

Advise the client to switch to a non-alcoholic beverage such as a cola drink:

While reducing alcohol intake is beneficial for managing OSAS, recommending a caffeinated beverage like cola is counterproductive. Caffeine can stimulate the nervous system and interfere with the ability to fall asleep, making it harder for the client to rest. A non-caffeinated alternative would be a better recommendation if alcohol is being limited.

Summary

The best option is to suggest that the client drink wine with dinner, ensuring it is consumed at least 3 hours before bedtime. This approach addresses the concern of alcohol impacting OSAS while respecting the client’s preferences, helping to improve their sleep quality. The other options either ignore the potential risks of alcohol and medication or suggest alternatives that could worsen the client’s sleep issues

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: Notify the healthcare provider (HCP) immediately.

Explanation

The priority action in this situation is to notify the healthcare provider (HCP) immediately because the client is likely experiencing alcohol withdrawal syndrome (AWS), specifically delirium tremens (DTs). Symptoms like diaphoresis (sweating) and visual hallucinations are indicative of severe alcohol withdrawal, which can be life-threatening if not treated promptly. Delirium tremens typically occurs 48-72 hours after the last alcohol intake, aligning with the client's postoperative timeline. Immediate notification to the healthcare provider is essential to begin appropriate interventions, such as IV fluids, thiamine, benzodiazepines, and monitoring to prevent complications like seizures and cardiovascular instability.

Why the other options are wrong

Discontinue the PCA pump

Discontinuing the morphine PCA pump is not appropriate without an order from the healthcare provider. While opioids can contribute to confusion and hallucinations, the client’s symptoms are more likely due to alcohol withdrawal. Pain management should continue as prescribed, and withdrawal symptoms should be managed separately with specific interventions targeting alcohol withdrawal.

Obtain the client's vital signs

Obtaining vital signs is important, particularly to assess for autonomic hyperactivity (e.g., tachycardia, hypertension, hyperthermia), but it is not the priority in this situation. The primary concern is addressing the client's symptoms of alcohol withdrawal and notifying the HCP immediately for further management. Vital signs can be assessed after notifying the provider to ensure a swift response to the potential life-threatening condition.

Assess the amount of morphine used in the last 8 hours

While it is relevant to review morphine use to identify possible opioid-related side effects, this is secondary to the immediate concern of alcohol withdrawal. Delaying intervention to assess morphine usage could increase the risk of further complications, including seizures or cardiac instability due to the withdrawal symptoms. Prompt medical evaluation should take precedence.

Summary:

The priority intervention is notifying the healthcare provider immediately, as the client is exhibiting symptoms of alcohol withdrawal, which requires urgent treatment to prevent life-threatening complications. While other actions such as monitoring vital signs or assessing morphine use are important, the priority is to address the alcohol withdrawal syndrome, which can cause severe complications if not promptly managed.

Correct Answer: Listen for changes in what the client hopes for and try to help him meet his goals.

Explanation

As a person approaches the end of life, their emotional and psychological needs shift. Terminally ill clients often begin to focus on short-term, meaningful goals such as seeking comfort, finding peace, or reconciling with loved ones. Actively listening for these changes and helping the client meet their evolving goals fosters emotional well-being and reduces feelings of hopelessness. This approach respects the client’s feelings, validates their needs, and allows them to retain a sense of control during a difficult period.

Why other options are wrong

Maintain a cheerful and calm appearance while spending time with the client:

While maintaining calmness is important, an overly cheerful demeanor may invalidate the client’s emotional state. Terminally ill clients may feel more supported when caregivers acknowledge the reality of their emotions rather than masking it with superficial cheerfulness. Offering genuine emotional support and being open to difficult conversations is more beneficial for addressing hopelessness.

Help save the client's energy by making as many decisions for him as possible:

This approach reduces the client’s autonomy, which can increase feelings of helplessness and hopelessness. Even in the face of terminal illness, maintaining a sense of control over decision-making helps preserve the client’s dignity and emotional well-being. Allowing the client to make decisions, as much as possible, is essential to their sense of control and emotional peace.

Offer meals prepared with the client's favorite foods at frequent, regular intervals:

Although offering comfort foods may seem caring, it may not address the client’s needs if their appetite has diminished due to the illness. Forcing regular meals can cause discomfort and may not align with the client’s wishes. The focus should be on providing nutrition when the client desires it, not on adhering to a strict feeding schedule. This approach overlooks the emotional needs and wishes of the client.

Summary

The best way to reduce the risk of hopelessness is to listen for and respond to the client’s shifting goals and emotional needs. This ensures that the client feels empowered, emotionally supported, and connected to their remaining desires. The other options either diminish the client’s autonomy, invalidate their emotions, or overlook their specific emotional and physical needs in the terminal phase.

The correct answer is: His serum lithium levels should be routinely evaluated

Explanation:

Lithium carbonate is a common medication used in the treatment of bipolar disorder, but it has a narrow therapeutic range, meaning the difference between an effective dose and a toxic dose is small. As a result, it is essential for individuals taking lithium to have regular monitoring of their serum lithium levels to ensure that they stay within the therapeutic range and do not become toxic. Routine monitoring of serum lithium levels is especially important when a client is transitioning to a more independent environment, such as living away from home, where they might have less direct supervision. Maintaining appropriate lithium levels helps prevent toxicity, which can cause severe side effects like tremors, confusion, and even organ damage. Therefore, the most important information to share with the family is the necessity for regular blood tests to monitor lithium levels.

Why the Other Choices Are Incorrect:

Despite his illness, the client should be able to live away from home

While it is certainly possible for individuals with bipolar disorder to live independently, this statement does not address the most critical aspect of managing his condition. The ability to live away from home is important, but regular monitoring of serum lithium levels is more essential to avoid complications from the medication. Therefore, this is not the most important piece of information to emphasize with the family.

He should plan to participate in group or individual therapy while at college

Participating in therapy is an important part of managing bipolar disorder, and it is something the client should consider. However, it is secondary to ensuring the safety and effectiveness of his medication regimen through regular lithium level monitoring. Therapy is beneficial but should not take precedence over ensuring that his medication levels are safe, as lithium toxicity can be life-threatening if left unchecked.

He should be aware of the symptoms of his illness

While it is important for individuals with bipolar disorder to be aware of their symptoms and signs of relapse or mania, monitoring lithium levels is more urgent for ensuring medication safety. Awareness of symptoms is important for long-term management, but regular blood tests are critical to avoid toxicity or suboptimal treatment, which can result in more severe consequences.

Summary:

The most important piece of information to provide the family is that routine monitoring of serum lithium levels is essential for ensuring that the client is within the therapeutic range for lithium and preventing toxicity. Although therapy and awareness of symptoms are also important, they are secondary to the immediate need for lithium level monitoring, especially when the client is transitioning to an independent living situation.

The correct answer is: Sleep at least 6 hours a night

Explanation:

The client's primary concerns, according to the scenario, include significant sleep disturbances (only 4 hours of sleep in the past 2 days) and weight loss (9 lbs in the last month). Sleep disturbances are a common symptom of depression and can worsen both physical and mental health. One of the initial goals in treating depression is to address basic physiological needs, including restoring normal sleep patterns. Achieving at least 6 hours of sleep per night within the first few days of treatment is important because adequate sleep plays a critical role in mental health stabilization, improving mood, and facilitating the healing process from depression.

Why the Other Choices Are Incorrect:

Meet scheduled appointment with dietitian

While addressing weight loss is important, the immediate priority should be stabilizing the client’s sleep patterns. Although meeting with a dietitian can be part of the treatment plan for nutrition and weight loss, sleep and mood stabilization typically come first in acute depressive episodes, as these factors directly impact the client's ability to function.

Understands the purpose of the medication regimen

Understanding the purpose of the antidepressant medication is important but is not the immediate priority. The client may be more focused on their physical symptoms (like sleep and weight loss) initially, and achieving sleep is a more urgent concern in the short term. Once the client’s sleep stabilizes, education about the medication regimen can be provided to ensure adherence and long-term treatment success.

Describes the reason for hospitalization

While the client’s understanding of why they are hospitalized is important, it is more of a long-term goal to promote insight into the condition. In the first few days, the immediate concern is physical stabilization (such as improving sleep and nutrition), as addressing these will help the client be more receptive to understanding the reasons for hospitalization and engaging in therapeutic activities.

Summary:

The most important goal in the first three days of treatment is to improve sleep (at least 6 hours per night) since this is a direct concern for the client, and adequate sleep is crucial for stabilizing mood and improving overall well-being in someone experiencing depression. Addressing sleep will also improve the client’s ability to engage in the rest of their treatment plan, including nutritional counseling and education about the medication.

The correct answer is: Acute confusion

Explanation:

The client presents with disorientation, disorganization, and confusion, which are clear signs of acute confusion. This symptom could be related to a variety of factors such as substance use, medical conditions (e.g., infections, electrolyte imbalances), or psychiatric disorders. Acute confusion, also known as delirium, is a medical emergency and requires immediate intervention to identify the underlying cause and ensure the safety of the client. The primary concern in this situation is to stabilize the client's condition, assess for any immediate life-threatening issues, and provide treatment or further evaluation as needed.

Why the Other Choices Are Incorrect:

Ineffective community coping

Although the client is homeless and may be facing challenges related to coping with living conditions, the priority issue based on the symptoms presented is acute confusion. Ineffective community coping may be relevant, but it is secondary to addressing the client's immediate safety and mental state. The confusion needs to be addressed first before focusing on community coping strategies.

Disturbed sensory perception

Disturbed sensory perception (such as hallucinations) could potentially be a problem for this client, especially given her suspiciousness. However, the primary concern is the client's acute confusion and ensuring she is stable and safe. Sensory disturbances can be considered later if it becomes clear that they are affecting her judgment or behavior in a more significant way.

Self-care deficit

A self-care deficit is a concern for clients who are unable to manage their personal care needs. While homelessness may contribute to difficulties with self-care, the client's acute confusion is the more pressing issue. Before addressing self-care, it is important to first stabilize the client's mental and cognitive functioning.

Summary:

The priority problem for this client is acute confusion, as she is exhibiting signs of disorientation and disorganization that require immediate assessment and intervention. After ensuring the client is medically stabilized, further assessments and interventions regarding other issues such as self-care or community coping can be addressed. The focus should first be on determining the cause of the confusion and stabilizing the client’s condition.