HESI NSG Mental Health Nursing (Exam 1)

Correct Answer:  b. Cyanosis

Explanation:

Cyanosis (bluish discoloration of the skin, lips, or extremities) is not a typical symptom of anorexia nervosa. It is usually associated with respiratory or cardiovascular issues, such as poor oxygenation, lung disease, or heart failure. While severe malnutrition can impair circulation, cyanosis is not a defining feature of anorexia.

Why the Other Options Are Expected Symptoms

a. Bradycardia (Slow Heart Rate) 

Common in anorexia nervosa due to malnutrition and decreased metabolic rate. The body conserves energy by slowing down heart function, leading to bradycardia (heart rate <60 bpm).

c. Lanugo (Fine, Soft Body Hair) 

Common in anorexia as the body tries to conserve heat due to extreme weight loss and lack of fat. Lanugo develops as a response to malnutrition to help maintain body warmth.

d. Edema (Swelling) 

Can occur due to fluid retention when the body is in starvation mode. Low protein levels (hypoalbuminemia) can cause peripheral edema (swelling in the legs, feet, or hands).

Refeeding syndrome—when a malnourished patient starts eating again—can also lead to fluid retention and swelling.

Summary:

While bradycardia, lanugo, and edema are all expected symptoms of anorexia nervosa, cyanosis is not a typical feature and is more commonly associated with oxygenation issues. Therefore, b. Cyanosis is the correct answer.

Correct Answer: Sleep disturbances

Explanation:

Antidepressants are most effective in alleviating sleep disturbances, which are common in depression. Many patients with depression experience insomnia, early morning awakenings, or hypersomnia, and antidepressants help regulate sleep patterns by restoring neurotransmitter balance (serotonin, norepinephrine, dopamine). SSRIs, SNRIs, TCAs, and mirtazapine all have varying effects on sleep, either improving it directly or indirectly as depression lifts.

Why the Other Options Are Incorrect:

Suicidal feelings

Incorrect, because while antidepressants can help reduce suicidality over time, they may initially increase suicide risk, especially in young adults. Close monitoring is required in the first few weeks of treatment.

Interpersonal problems

Incorrect, because social and relationship difficulties are often a consequence of depression rather than a direct symptom. Antidepressants may help improve mood and energy, but therapy (CBT, interpersonal therapy) is more effective in resolving interpersonal issues.

Anxiety disorders

Incorrect, because while some antidepressants (SSRIs, SNRIs, TCAs) are used to treat anxiety, they take longer to be effective for anxiety compared to sleep disturbances. Benzodiazepines or CBT may be used in conjunction with antidepressants for faster symptom relief in anxiety disorders.

Summary:

Antidepressants are most effective in alleviating sleep disturbances in depressed patients. Suicidal thoughts, interpersonal problems, and anxiety disorders may improve over time, but these issues often require additional interventions like therapy or crisis management.

Correct Answer: c. The patient is unconsciously using a defense mechanism to protect against the repeated memory of the attack.

Explanation:

The patient's inability to remember the attack is likely due to repression, a psychological defense mechanism in which distressing thoughts or traumatic experiences are unconsciously blocked from conscious awareness. This is a common response to severe trauma, as the brain attempts to protect the individual from overwhelming emotional distress.

Why the Other Options Are Incorrect:

a. The woman lost consciousness and was not cognitively aware of what happened during the attack – If the patient had lost consciousness, she would not have been able to encode the memory in the first place. However, repression refers to a psychological blocking of an event that was consciously experienced.

b. The brain has produced a chemical anemia that will repress the memories of the attack indefinitely – There is no such thing as "chemical anemia" in memory processing. While stress hormones like cortisol can impact memory formation, repression is a psychological process, not a chemical one.

d. It is a temporary suppression of the attack; her memory will return when she is physically and emotionally ready to handle the memories – While some repressed memories may resurface later, it is not guaranteed, and repression is different from suppression (which is a conscious effort to forget something).

Summary:

The patient's memory loss is best explained by repression, a defense mechanism that protects against distressing memories. This makes option C the correct answer.

Correct Answer:

d. Echolalia

Explanation:

Echolalia is a common feature of language development in autistic children. It refers to the repetition of words or phrases that the child hears, often without understanding their meaning. It can be:

• Immediate echolalia – The child repeats words or phrases right after hearing them.


• Delayed echolalia – The child repeats words or phrases later, sometimes out of context (e.g., repeating a TV commercial phrase when asked a question).

Echolalia can be a self-soothing mechanism or a way for autistic children to process language before they develop meaningful communication skills. Some children eventually outgrow it, while others continue to use it in specific contexts.

Why the Other Options Are Incorrect:

• a. Scanning speech
  
  
  
  
  • Incorrect because scanning speech refers to an irregular speech pattern where words are spoken slowly, with pauses (often seen in neurological disorders like multiple sclerosis). It is not characteristic of autism.
  
  
  
  


• b. Speech lag
  
  
  
  • Incorrect because while many autistic children do experience delayed speech development, echolalia is a more specific feature of their language pattern. "Speech lag" is a general term and does not accurately describe the repetitive nature of autistic speech.
  
  
  
  


• c. Stuttering
  
  
  
  • Incorrect because stuttering (shuttering is likely a typo) is a speech disorder involving repetitions, prolongations, or blocks in speech. It is not a hallmark feature of autism but rather a distinct speech disorder.
  
  
  
  

Summary:

Autistic children often exhibit echolalia (option d), a speech pattern characterized by the repetition of words or phrases. Other options describe different speech issues that are not specifically linked to autism.

Correct Answer: A - Ask the adolescent sitting on the couch to join the group at the table.

Rationale:

Group interaction and engagement improve when all members are physically close and included in the same space. Asking the adolescent on the couch to join the others at the table promotes active participation, eye contact, and equal involvement in the discussion. This reduces distractions and enhances group cohesion, making assertive communication more effective.

Why the Other Options Are Incorrect:

B - "Suggest that they all sit together to increase the interaction."

While the intention is good, "suggesting" rather than directly asking the adolescent to move may not be as effective in ensuring group cohesion. A more directive approach (Option A) is preferable in a structured learning setting.

C - "Allow the adolescents to sit wherever they wish as long as they participate."

Physical separation can hinder engagement, especially in communication-based discussions. Body language and face-to-face interaction are essential for assertive communication, so seating arrangement matters.

D - "Determine which adolescents would like to participate in the discussion."

This does not address the seating issue, which is key to group interaction. Encouraging participation is important, but physical inclusion is the first step to ensuring engagement.

Summary:

To facilitate group interaction, the nurse should ask the adolescent on the couch to join the others at the table, ensuring equal participation and effective assertive communication practice.

The correct answer is C. Establish trust by providing a calm, safe environment.

Rationale:

Establishing trust and a safe environment is essential for any therapeutic relationship, especially for a client with agoraphobia. Without trust, the client may not feel comfortable progressing through the desensitization process or sharing their fears and anxieties. Creating a calm and safe space is the foundation for successfully implementing the therapy.

Why other options are incorrect:

A. Encourage substitution of positive thoughts for negative ones: While cognitive restructuring is important, the priority at the initial stage of therapy for agoraphobia is establishing a safe and supportive environment, which is essential for engagement in therapy.

B. Encourage deep breathing when anxiety escalates in a crowd: Although deep breathing is a helpful coping strategy for managing anxiety, it should come after the initial establishment of trust and a safe environment. The client needs to feel secure before using techniques to manage their anxiety.

D. Progressively expose the client to larger crowds: Progressive exposure is a key part of desensitization, but this process cannot be effectively started without first establishing trust and a safe environment. If the client does not feel safe, progressive exposure will not be effective.

Summary:

The priority in the care plan for a client with agoraphobia undergoing desensitization therapy is to first establish trust and create a calm, safe environment. This provides the foundation needed for successful therapeutic work, including progressive exposure to crowds and other therapeutic techniques such as deep breathing.

Correct Answer: D. Reports of fatigue accompanied by fever.

Rationale:

Clozapine is an atypical antipsychotic used to treat schizophrenia, but it carries a risk of agranulocytosis, a life-threatening condition characterized by a dangerously low white blood cell (WBC) count. Signs of agranulocytosis include fatigue, fever, sore throat, and signs of infection, which require immediate medical intervention. Agranulocytosis can lead to severe infections and sepsis if not detected early. Clozapine requires regular WBC and absolute neutrophil count (ANC) monitoring to prevent and detect this side effect.

Why the Other Options Are Incorrect:

A. Greater frequency and urgency with urination.

This may suggest diabetes or a urinary tract infection (UTI), but it is not the most urgent concern related to clozapine. Clozapine can cause metabolic side effects, including increased blood sugar, but this does not require immediate HCP notification like fever and fatigue.

B. Recurrent bouts of insomnia at night.

Insomnia is a common side effect of antipsychotic medications and can often be managed with sleep hygiene techniques or medication adjustments. It is not an emergency and does not indicate a life-threatening complication like agranulocytosis.

C. Increased tendency to bruise easily.

Easy bruising could suggest a clotting disorder, thrombocytopenia, or medication-induced effects, but clozapine does not primarily cause platelet dysfunction. While this should be evaluated, it is not as critical as signs of agranulocytosis, which requires immediate action.

Summary:

Fatigue and fever in a client taking clozapine could indicate agranulocytosis, which is a medical emergency. Immediate reporting and WBC/ANC monitoring are necessary to prevent serious infection or sepsis.

Correct Answer: d. Loosening of association

Explanation:

Loosening of association is a thought disorder in which a person’s ideas shift from one subject to another in an illogical or unrelated manner. The statements "Yes, it's March, March is little woman. That's literal you know" demonstrate a disorganized thought process where the connections between words or ideas do not follow logical reasoning. This is a classic symptom of schizophrenia.

Why the Other Options Are Incorrect:

a. Neologisms

Incorrect because neologisms refer to made-up words that have no meaning to others but may have personal significance to the client. Example: "The wibberlog makes me feel happy." In the given statement, the words used are real words, but they are disorganized, not invented.

b. Echolalia

Incorrect because echolalia refers to repeating words or phrases spoken by others, often seen in autism, catatonia, or neurological disorders. The client’s response is not a repetition but rather a disorganized thought process.

c. Flight of ideas

Incorrect because flight of ideas involves rapidly shifting from one topic to another, typically seen in mania (bipolar disorder). In loosening of associations, the connection between thoughts is unclear, whereas in flight of ideas, there is some logical connection between topics, but the speech is very fast.

Summary:

The correct answer is (d) Loosening of association, as the client’s speech is fragmented and lacks a logical connection. The other options describe different speech disturbances, but they do not fit this specific pattern of disorganized thinking seen in schizophrenia.

Correct Answer: Death of a spouse

Explanation:

The death of a spouse is a major life stressor that can significantly increase the risk of suicide. Losing a spouse often leads to:

Intense grief and loneliness

Depression (a key risk factor for suicide)

Loss of social and emotional support

Potential financial stressors

Studies show that widowed individuals, especially older adults and men, have a higher suicide risk compared to those who are married or single.

Why Other Options Are Incorrect:

Moving

While stressful, moving alone does not typically lead to suicidal ideation. The risk may increase if the move is related to isolation or loss of a support system, but not as significantly as losing a spouse.

Changing Jobs

Job changes can cause stress and uncertainty, but they are generally not as traumatic as the death of a loved one. The exception would be job loss or financial ruin, which can increase suicide risk.

Illness

Chronic illness or terminal disease can elevate suicide risk, especially in cases of chronic pain or loss of independence. However, not all illnesses pose a high suicide risk, and the impact varies depending on the severity of the condition and the patient’s coping mechanisms. The death of a spouse generally carries a more immediate and severe psychological impact.

Summary:

The death of a spouse is the strongest risk factor for suicide among the options given, particularly in older adults and men, as it can lead to profound loneliness, depression, and loss of purpose. Other stressors like moving, job changes, and illness may contribute to distress but do not pose as immediate a risk.