HESI Mental Health

Correct Answer:

"Yes, I see. Go on."

Explanation:

Offering a general lead is a therapeutic communication technique in which the nurse encourages the client to continue talking or elaborate on their thoughts. It is a way of showing interest in what the client is saying and prompting them to share more information. The phrase, "Yes, I see. Go on," is an example of this technique because it subtly invites the client to continue their conversation without interrupting or directing it too much.

Why the other options are incorrect:

"Do you know why you are here?"

This is an example of a closed-ended question, which is focused on obtaining specific information and may limit the client’s ability to expand on their thoughts. It’s not a general lead because it doesn’t invite the client to elaborate freely.

"Are you feeling depressed or anxious?"

This is another example of a closed-ended question, asking for specific information about the client’s emotional state. It limits the client's response and does not encourage them to elaborate or continue their narrative, as a general lead would.

"Can you chronologically order the events that led to your admission?"

This is an example of a directing question, which asks the client to perform a specific task. It is more structured and less open-ended than a general lead, which would encourage the client to speak freely without guiding them toward a specific response.

Summary:

A general lead is used to encourage the client to continue speaking and elaborate on their thoughts. The response "Yes, I see. Go on," is an example of this technique because it supports the client's verbalization in an open-ended way. Other options involve more structured or closed questions, which do not provide the same open invitation to continue sharing.

The correct answer is:

C. Stop taking the medication if intended effect is not immediate.

Explanation:

This statement requires additional instruction because lorazepam, a benzodiazepine, may not provide immediate relief for all symptoms, especially in the early stages of treatment. While it acts relatively quickly to reduce acute anxiety, clients should be advised not to stop the medication abruptly if they do not feel immediate effects. Sudden discontinuation can lead to withdrawal symptoms such as insomnia, irritability, or seizures, especially if the medication is taken for an extended period. Clients should be encouraged to follow the prescribed regimen and consult their healthcare provider if they have concerns about the medication’s effectiveness.

Why the other options are incorrect:

A. Move slowly from a sitting position to a standing position:

This is correct advice. Lorazepam can cause dizziness, lightheadedness, or orthostatic hypotension, especially when moving quickly from sitting or lying to standing. Teaching the client to change positions slowly helps prevent falls and injury.

B. Use relaxation techniques to reduce excessive anxiety:

This is appropriate guidance. While lorazepam treats acute anxiety symptoms, non-pharmacological approaches such as deep breathing, meditation, and mindfulness complement medication and provide long-term anxiety management.

D. Avoid alcohol and other sedatives while taking the medication:

This is correct advice because combining lorazepam with alcohol or other central nervous system depressants can lead to excessive sedation, respiratory depression, and potentially life-threatening complications. Clients should be instructed to avoid substances that enhance sedation while taking lorazepam.

Summary:

The statement requiring additional instruction is “Stop taking the medication if intended effect is not immediate.” Clients need to understand that they should not discontinue lorazepam without consulting their healthcare provider, even if relief is not immediate. Proper education about the medication’s effects, safety precautions, and the importance of gradual discontinuation is essential for safe and effective use.

Correct Answer: Acknowledge the client's anger and attempt to address its source.

Explanation

Acknowledging the client's anger and exploring its underlying causes is crucial in managing the emotional response to a new, life-threatening diagnosis. Anger is a natural part of the grieving process, and by validating the client's feelings, the nurse fosters an environment where the client feels heard and understood. This can reduce distress and improve communication, helping the healthcare team better understand the client's emotional state. Addressing the source of the anger allows for targeted support, which can ease frustration and clear any misunderstandings, enabling the client to begin processing their diagnosis in a healthier way.

Why other options are wrong

Arrange for the client to meet another client who has lung cancer:

While peer support can be helpful, it may not be the right first step when the client is experiencing acute anger. Introducing another client too soon could cause further frustration, or the client may feel rushed into connecting with others before their own feelings are validated. Acknowledging the anger and addressing its source should be the immediate focus.

Allow the client and family time to be alone:

While privacy can be beneficial, leaving the client to deal with their anger alone may worsen feelings of isolation. Clients facing a life-threatening diagnosis need emotional support and open communication, which can be more effectively facilitated by a nurse who acknowledges their anger and addresses the emotional concerns behind it.

Request a consult from an oncology social worker:

Involving an oncology social worker can provide additional long-term emotional support, but it is not the most immediate intervention. Before referring to other resources, the nurse should first address the client's immediate emotional state, particularly the anger. This ensures that the client's concerns are validated in the moment, fostering a stronger sense of trust and support.

Summary

The most important intervention is to acknowledge and address the client's anger directly. This approach supports emotional expression, validates the client’s feelings, and sets the stage for open communication and more effective coping. While peer support, privacy, and social work referrals may be valuable later, addressing immediate emotional distress is key to managing the situation and helping the client navigate the challenges of their diagnosis.

The correct answer is:

"Tell me more about the incident that causes you to feel like the rape just occurred."

Explanation:

When a client is experiencing distress related to a traumatic event such as sexual assault, it is essential for the nurse to provide a safe, non-judgmental space for the client to express their feelings and experiences. The client’s statement that it feels as though the rape "just happened yesterday" indicates that they are struggling with the emotional aftermath of the trauma. Asking the client to share more about the incident helps the nurse understand the client's emotional state and facilitates the processing of the trauma. It demonstrates empathy and encourages the client to verbalize their feelings, which is an important aspect of trauma-informed care.

Why the Other Choices Are Incorrect:

"You need to try and be realistic. The rape did not just occur.":

This response is dismissive and invalidates the client’s feelings. Telling the client to "try and be realistic" minimizes their experience and could lead the client to feel misunderstood or rejected. It's essential to acknowledge the client’s emotions without minimizing or rushing the healing process.

"It will take some time to get over these feelings about your rape.":

While this statement is true in some cases, it is too general and doesn't engage the client in a meaningful way. Simply telling the client that it will take time to "get over" the feelings does not provide the therapeutic space for the client to express their specific emotions or understand their unique experience. Healing is individualized, and it’s important to help the client explore their feelings.

"What do you think that you can do to alleviate some of your fears about being raped again?":

While addressing safety concerns is important, this question shifts the focus away from exploring the client’s immediate emotional experience of the trauma. The focus should first be on listening to and validating the client's current emotional state. Once the client has been given space to process their feelings, the nurse can help them develop coping strategies and safety plans.

Summary:

The most appropriate response to the client’s statement is "Tell me more about the incident that causes you to feel like the rape just occurred." This response encourages the client to talk about their feelings and the impact of the trauma, providing an opportunity for therapeutic dialogue. It is important for the nurse to listen and support the client in processing their emotions rather than dismissing or generalizing their experience.

Correct Answer:

Insight and judgment

Explanation:

The mental status exam (MSE) is a structured assessment of a client's cognitive, emotional, and behavioral functioning. The insight and judgment section evaluates the client's awareness of their illness and decision-making ability.

The client's statement, "I don't need to be here," reflects poor insight because it shows a lack of understanding or denial of the need for treatment despite being hospitalized by court order.

The belief that "the TV talks to her" is a delusion or hallucination, which indicates impaired judgment due to disorganized thought processes or psychosis.

Both statements reflect problems in how the client perceives reality and understands the necessity for treatment, which are key indicators of insight and judgment issues.

Why the other options are incorrect:

Mood and affect:

This section evaluates the client’s emotional state (mood) and observable emotional expression (affect). The client’s statements do not describe emotions like sadness, anxiety, or flat affect. Instead, these statements relate to cognition and perception of reality.

Remote memory:

This refers to long-term memory or the recall of past events (e.g., childhood memories). The client’s current beliefs about hospitalization and the TV talking do not involve past memories, so this section is not applicable.

Level of concentration:

This assesses the client’s attention span and ability to focus on tasks (e.g., counting backward or spelling a word). The content of the client’s speech does not reflect concentration issues but rather disordered thinking related to insight and judgment.

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.

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.

Correct Answer: Educate the client about the purpose and side effects of the medication.

Explanation:

The priority when preparing a client for discharge with a new medication for managing cocaine cravings is to provide thorough education about the medication. This includes explaining the purpose of the medication, how it works, potential side effects, and the importance of adherence. Education empowers the client to use the medication correctly, improving compliance and helping to reduce the risk of relapse. It also ensures that the client can identify and manage any adverse effects they might encounter. This intervention plays a key role in promoting long-term recovery and reducing misunderstandings that could lead to premature discontinuation or misuse of the medication.

Why the Other Options Are Incorrect:

Determine when the client last used cocaine:

While it is important to know the client’s last cocaine use to monitor for withdrawal symptoms or assess the need for immediate interventions, this is not the priority at discharge. The focus during discharge should be on ensuring the client understands how to manage their medication for cocaine cravings effectively.

Encourage the client to take the medication even if the symptoms are relieved:

Although encouraging medication adherence is important, the priority should be educating the client about the importance of continuing the medication, not just instructing them to take it. Educating the client about why they need to continue the medication, even if they feel better, helps foster long-term adherence.

Assess the client for symptoms of cocaine withdrawal:

Cocaine withdrawal is generally not life-threatening, unlike withdrawal from alcohol or opioids. While ongoing monitoring for withdrawal symptoms is necessary during treatment, the immediate priority at discharge is to ensure the client understands how to safely use the prescribed medication to manage cravings.

Summary:

The best intervention at discharge is educating the client about the purpose and side effects of the medication, as this will promote adherence and reduce the risk of relapse. Other actions, like assessing withdrawal symptoms or encouraging medication use, are important but secondary to ensuring the client is well-informed and prepared to manage their medication in the long term.

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.