HESI RN 31I Pharmacology Exam

The correct answer is D: My name tag shows that I am a nurse here.

Explanation of the correct answer:

D. My name tag shows that I am a nurse here.

In the case of schizophrenia, clients may experience delusions, where they believe things that are not true. The most therapeutic response is to gently correct the delusion without directly confronting or arguing with the client about their beliefs. By calmly stating the truth (that the nurse is a nurse, not one of their children), the nurse provides a reality-based response that doesn't escalate the situation or challenge the client's beliefs in an aggressive or confrontational manner. The goal is to validate the client's feelings while reorienting them to the present reality.

Why the other options are incorrect:

A. I know that you don't have 20 children.

This response directly challenges the client's delusion, which can be seen as invalidating or dismissive. In patients with schizophrenia, directly confronting or disputing delusions often leads to increased anxiety or agitation, and the client may become defensive or upset.

B. Let's go ask another nurse if this is true.

While this response may seem to provide reassurance, it still indirectly engages with the delusion, encouraging the client to continue questioning reality in an unhelpful way. This approach doesn't provide a grounding or therapeutic correction to the client's false belief.

C. I cannot possibly be one of your children.

This response is too blunt and confrontational. It not only challenges the delusion but also does not provide an opportunity for the nurse to correct the reality in a calm and therapeutic way. It could escalate the situation, making the client feel misunderstood.

Correct Answer B: Complete a suicidal risk assessment.

Explanation:

Immediate Safety and Risk Evaluation:

The presence of scars on both wrists combined with the client's report of fears about self-harm are strong indicators of potential suicidal ideation or active self-injurious behavior. In this context, the nurse's top priority is to assess the client’s level of suicidal risk to determine if she is in immediate danger and whether she requires urgent psychiatric intervention or hospitalization. This includes evaluating the frequency, intent, plan, means, and previous attempts to self-harm or attempt suicide.

Purpose of a Suicide Risk Assessment:

A suicidal risk assessment helps the nurse understand the seriousness and immediacy of the threat. It provides vital information for determining next steps in care—such as initiating suicide precautions, involving the mental health team, or arranging a safe environment. Without this assessment, the nurse cannot safely proceed with any other aspect of care, because protecting life takes precedence.

Why Other Options Are Incorrect:

A: Explore the client's current life events

While understanding life events is important for broader care planning and emotional support, this is not the priority when the client has shown both verbal and physical indicators of potential suicide. Life events can be explored after confirming safety.

C: Assess for body image disturbance

Body image concerns may be relevant in adolescent females, especially those who self-harm, but this is secondary to the concern about suicide. The nurse must first ensure the client is safe before addressing underlying issues.

D: Praise her for seeking professional help

Positive reinforcement is helpful in promoting help-seeking behavior, but in this situation, it is not the nurse’s immediate priority. Focusing on emotional safety and determining suicide risk comes before offering praise or therapeutic reflection.

Correct Answer C: Subconscious blame toward the client for staying in an abusive relationship.

Explanation:

Subconscious Blame Toward the Client for Staying in an Abusive Relationship:

The nurse may feel anger, frustration, or helplessness because, at a subconscious level, they might believe that the client should leave the abusive relationship. This can be due to societal expectations that victims of abuse should simply walk away from their situation. However, the dynamics of intimate partner violence are incredibly complex, and many victims feel trapped, isolated, or even manipulated into staying. The nurse may not fully realize it, but they may be subconsciously blaming the client for not leaving, causing feelings of frustration and helplessness.

Psychological Impact on the Nurse:

The nurse’s reaction might also stem from their own struggle with the inability to help the client in a way they believe is effective. They may want to “fix” the situation or rescue the victim, but they cannot do so, leading to feelings of powerlessness or anger. This can create tension in the nurse’s emotional response, which can be mistakenly directed at the client as if they have more control over the situation than they do.

Cultural and Societal Beliefs:

There are often societal or cultural assumptions that people have the ability to change their circumstances if they choose to. When faced with a victim of intimate partner violence, the nurse may unintentionally project these assumptions onto the client, leading to internal judgment or feelings of anger. This belief, however, overlooks the psychological manipulation, fear, and barriers that keep victims in abusive relationships.

Why Other Options Are Incorrect:

A: Difficulty accepting the explanation about how the injuries actually occurred.

This is not likely the cause of the nurse's emotions. While it’s possible to feel disbelief about the nature of the injuries, it’s the emotional reaction of anger and helplessness that’s being discussed here. The issue is not necessarily the explanation of the injuries, but rather the deeper, subconscious judgments that can emerge when dealing with an abusive situation.

B: Feelings are influencing the client's care due to a personal history of abuse.

While a nurse’s personal history of abuse can influence their reactions, this would not be the primary cause in this case. The emotions described—anger, helplessness, and frustration—are more likely linked to subconscious blame about the victim’s decisions rather than any specific personal experience of the nurse.

D: Experience in caring for clients who are affected by family violence is limited.

While limited experience can contribute to feelings of discomfort or inadequacy, it does not directly explain the specific emotions of anger, embarrassment, and helplessness. The nurse's feelings are more likely a result of the complex dynamics of abuse and the nurse's internal response to these dynamics.

The correct answer is C: Lorazepam 2 mg PO bedtime.

Explanation of the correct answer:

C. Lorazepam 2 mg PO bedtime

Lorazepam is a benzodiazepine that is commonly used for its anxiolytic (anxiety-reducing) and sedative properties. The client is reporting being "so upset" that she cannot sleep, which suggests anxiety or stress as the primary issue. Lorazepam would help address both her anxiety and her difficulty with sleep, making it the most appropriate choice in this scenario. Additionally, it is commonly prescribed for short-term management of anxiety symptoms, especially during periods of significant stress like starting chemotherapy.

Why the other options are incorrect:

A. Ondansetron 8 mg PO three times a day PRN

Ondansetron is an antiemetic used to prevent and treat nausea and vomiting, commonly prescribed for clients undergoing chemotherapy. However, the client's primary complaint is related to anxiety and insomnia, not nausea or vomiting. Therefore, ondansetron would not address the current symptoms of anxiety and difficulty sleeping.

B. Oxycodone, acetylsalicylic acid one tablet PO every 4 hours PRN

Oxycodone is an opioid pain medication, and acetylsalicylic acid (aspirin) is a nonsteroidal anti-inflammatory drug (NSAID). While these medications may help manage pain, the client is not reporting pain as her primary issue. In fact, opioids should be used cautiously in non-pain situations due to their sedating effects and potential for dependence. This medication combination would not address the anxiety and insomnia described in the situation.

D. Acetaminophen, diphenhydramine 2 capsules bedtime

Acetaminophen is a pain reliever and diphenhydramine is an antihistamine with sedative properties that can help with sleep. However, the client's primary complaint is anxiety rather than pain. Diphenhydramine might help with sleep, but it does not address the underlying anxiety, and its sedative effects might not be as effective as a benzodiazepine like lorazepam in managing the level of distress the client is experiencing.

Correct Answers:

A – Assign the client to a single room,

C – Give concise and firm directions for hygiene and dressing,

D – Invite for a walk when client's energy is high.

Explanation:

A – Assign the client to a single room:

Clients in the manic phase of bipolar disorder can be intrusive, overly talkative, hypersexual, and distractible. Assigning the client to a single room helps reduce stimulation and minimize conflicts with others. It also decreases environmental triggers that could escalate manic behavior, supports better rest, and protects other clients from inappropriate comments or actions.|

C – Give concise and firm directions for hygiene and dressing:

During mania, concentration and decision-making are impaired, so it’s important to give simple, structured commands. Clear and brief instructions help guide the client through tasks they might otherwise neglect or be unable to complete due to distractibility or grandiosity.

D – Invite for a walk when client's energy is high:

Clients in a manic state often have excessive energy and restlessness. Channeling this energy into noncompetitive, structured physical activity (like walking) helps reduce agitation and promote safe expression of energy. It also aids in improving focus and rest.

Why Other Options Are Incorrect:

B – Provide television programs with suspense to keep attention engaged:

Suspenseful or stimulating content can increase agitation, paranoia, or disorganized thinking in a manic client. It’s better to provide calming, low-stimulation activities that support grounding and rest.

E – Engage the client in competitive activities:

Competitive activities can exacerbate manic symptoms, increase irritability, and trigger aggression or interpersonal conflict. Structured, low-stimulation, and non-competitive tasks are more appropriate to maintain emotional stability.

The correct answers are

C. Sleep patterns

F. Substance abuse (drugs or alcohol)

G. Recent losses experienced

H. Medication list from home

Explanation of the correct answers:

C. Sleep patterns

The client reports disruptive sleep habits, such as difficulty sleeping at night and wanting to sleep a great deal during the day. This is an important symptom as it could indicate depression or another underlying mental health issue, which is consistent with the client's general malaise, fatigue, and withdrawal. Sleep disturbances are a key factor in diagnosing mood disorders, such as depression, and should be thoroughly assessed.

F. Substance abuse (drugs or alcohol)

The client reports drinking a six-pack of beer daily for the last eight months, which raises concerns about alcohol use disorder. Chronic alcohol use can contribute to mental health symptoms like fatigue, malaise, and decreased appetite, as well as exacerbate any underlying mood or psychiatric disorders. Substance abuse is a critical factor to consider in the assessment, as it can affect both physical and mental health and influence treatment plans.

G. Recent losses experienced

Although the client does not directly mention recent losses, it is important to inquire about any losses, whether personal (such as the death of a loved one) or social (such as a job loss or relationship difficulties), as these can trigger or worsen symptoms of depression. Losses are a common precipitating factor for mood disorders, and the client's withdrawn behavior and reported lack of energy could be indicative of this.

H. Medication list from home

Knowing the medications the client is taking is important because certain medications can contribute to symptoms like fatigue, decreased appetite, or sleep disturbances. It is also crucial to rule out any adverse effects of prescribed medications or interactions with substances like alcohol. For example, some psychiatric or non-psychiatric medications can have side effects that overlap with the client's reported symptoms.

Why the other options are less relevant:

A. Vaccination status

While vaccination status is important in some cases, it is not as critical in this scenario. The client's primary concerns involve mental health and possible substance abuse, which should take priority. Vaccination status would only be relevant if the client presented with symptoms suggestive of an infectious disease or if there were a history of travel to areas where vaccinations are important.

B. Travel history

The travel history is unlikely to be a major factor in this case unless there were specific risk factors suggesting exposure to infections or diseases during travel. Given the client's presentation of mood-related symptoms, it seems that the primary concern lies with his mental health and alcohol use, not travel-related illnesses.

D. Relationships

While relationships can play a role in mental health, the client has not mentioned significant relationship difficulties. Although social isolation may be an underlying issue, at this point, the focus should be on addressing immediate symptoms such as sleep disturbances, alcohol use, and possible mood disorder, rather than specifically addressing relationship factors.

E. Work responsibilities

The client's work responsibilities are somewhat relevant since he has missed five days of work in the past two weeks due to feeling poorly. However, the client's general malaise and withdrawal are more concerning at this point and likely contribute to his inability to fulfill work responsibilities. The focus should be on understanding the underlying cause of his symptoms (e.g., mental health or substance abuse) rather than specifically on his work situation at this stage.

Correct Answer B: I have three firearms locked in a safe at home.

Explanation:

Suicide Risk Assessment:

The presence of firearms is one of the most significant risk factors for suicide. The availability of lethal means significantly increases the likelihood of a successful suicide attempt. Even if the firearms are stored in a safe, the nurse must be concerned about the possibility of the client gaining access to them during a moment of crisis or impulsivity. Therefore, documenting this information is critical for safety planning and determining whether the firearms need to be temporarily removed or securely locked away by someone else.

Why Other Options Are Incorrect:

A: My panic attacks happen once every month. 

While panic attacks can cause distress and anxiety, this statement does not directly indicate suicidal ideation or access to lethal means. Panic attacks may be concerning, but they are not as immediate a risk as the availability of firearms.

C: I just feel like my life is filled with emptiness.

This statement may indicate hopelessness and depression, both of which are significant risk factors for suicide. However, this comment is more abstract and does not directly suggest the presence of a specific, immediate risk, such as access to lethal means.

D: My daughter is the only reason I keep trying. 

This statement can indicate attachment and may suggest that the client has some protective factors (such as their love for their daughter). However, it still indicates suicidal ideation, which is a serious concern, but it does not highlight the immediate risk posed by the access to firearms.

The correct answer is A: Evaluate the client's mood, cognition, and orientation.

Explanation of the correct answer:

A. Evaluate the client's mood, cognition, and orientation

The mental status exam (MSE) is a structured tool used to evaluate a client's current mental state and psychological functioning. It is designed to assess key aspects of the client's mental health, such as their mood, cognitive abilities (e.g., memory, attention, judgment), and orientation (e.g., awareness of time, place, and person). These components help the nurse understand the client's overall psychological state and guide further assessment or treatment decisions.

Why the other options are incorrect:

B. Assess functional ability of the primary support system

The mental status exam focuses on the client’s mental functioning, not the functioning of their support system. While family or social support may be discussed in the broader assessment process, the MSE itself does not evaluate the support system’s role or functioning.

C. Review the client's pattern of adaptive coping skills

While understanding coping skills is important in assessing a client’s mental health, the mental status exam does not specifically focus on adaptive coping skills. Instead, it is aimed at evaluating more immediate aspects of the client’s mental and emotional state, such as their mood and cognitive abilities.

D. Determine the client's level of emotional functioning

Emotional functioning is a part of the mental status exam, particularly in assessing mood. However, the MSE is much broader and also includes aspects such as cognition and orientation. The primary purpose of the MSE is to provide a more comprehensive evaluation of the client’s overall mental status.

Correct Answer A: An adolescent who is depressed over not being accepted by peers.

Explanation:

Role Playing for Social Skill Development and Emotional Processing:

Role playing is a therapeutic technique used to help individuals explore emotions, develop interpersonal skills, practice responses to social situations, and gain insight into others' perspectives. It is especially effective for adolescents because they are at a developmental stage where peer acceptance, identity formation, and social interaction are central concerns. When an adolescent is experiencing depression due to social rejection or lack of acceptance, role playing allows them to practice assertiveness, receive feedback in a safe environment, and build confidence in interacting with peers. It can also help them better understand their own emotional responses and improve coping strategies.

Why Other Options Are Incorrect:

B: An older adult resident of a long-term care facility who sometimes takes other residents' belongings:

While behavioral issues in long-term care residents can sometimes be addressed through behavioral therapies, role playing is less effective with older adults experiencing cognitive decline or confusion, which is often the case in such settings. The therapeutic approach here would more likely involve environmental cues, redirection, or behavioral modification.

C: An adult with schizophrenia who often refuses to take prescribed antipsychotic medications:

Clients with schizophrenia, especially those with poor insight (anosognosia), may not respond effectively to role playing because disorganized thinking, delusions, or hallucinations can interfere with the ability to engage meaningfully in the activity. Motivational interviewing or psychoeducation would be more appropriate interventions.

D:  A hyperactive 4-year-old who has recently been tested for autism:

While play therapy is suitable for young children, structured role playing may be too complex for a 4-year-old, especially if they are on the autism spectrum, where social communication and imaginative play may be significantly impaired. Interventions here are usually highly structured and based on behavioral approaches or developmental therapies.