HESI NSG Mental Health Nursing (Exam 1)

Correct Answer: c. Adolescent onset

Explanation:

According to the DSM-5, conduct disorder (CD) onset is categorized as follows:

Childhood-onset (Before age 10):

Symptoms appear before 10 years old. More severe and persistent behaviors Higher risk of developing antisocial personality disorder (ASPD) in adulthood

Adolescent-onset (Age 10 or later):

Symptoms first appear at age 10 or later. Behaviors are often less aggressive and more influenced by peer pressure. Less risk of long-term antisocial behavior

Unspecified-onset:

Used when the exact age when symptoms began is unknown. Since Liam’s behaviors started around his 11th birthday, this places him in the adolescent-onset category. The DSM-5 specifically states that adolescent-onset occurs at age 10 or later, which includes 11.

Why the Other Options Are Incorrect:

a. Unspecified onset 

This applies when the age of onset is unclear, but in Liam’s case, we know the behaviors started around age 11.

b. Behavior-induced onset 

This is not a recognized DSM-5 classification for conduct disorder. CD is categorized based on age of onset, not behavior triggers.

d. Childhood onset 

Childhood onset requires symptoms before age 10. Since Liam’s behaviors began at 11, this does not fit childhood-onset criteria.

Summary:

Liam's conduct disorder fits the adolescent-onset type (c) because his symptoms began at age 11, which is after age 10. The DSM-5 differentiates childhood and adolescent onset based solely on age, making adolescent onset the correct classification in this case.

Correct Answer: Polycythemia

Explanation

Polycythemia (an increased number of red blood cells) is a common finding in clients with chronic obstructive pulmonary disease (COPD). In COPD, chronic hypoxia (low oxygen levels) stimulates the kidneys to release erythropoietin, which promotes increased red blood cell production to compensate for inadequate oxygenation. This results in secondary polycythemia, which helps improve oxygen transport but also increases blood viscosity, raising the risk of complications like blood clots.

Explanation of Incorrect Answers:

Respiratory Alkalosis

Clients with COPD are more likely to experience respiratory acidosis, not alkalosis. COPD leads to chronic CO₂ retention due to impaired gas exchange, which lowers blood pH and causes acidosis. Respiratory alkalosis (high pH, low CO₂) is more commonly seen in conditions involving hyperventilation, not COPD.

Decreased Troponin Levels

Troponin is a cardiac biomarker used to detect heart damage (e.g., myocardial infarction). COPD does not directly cause changes in troponin levels unless there is an accompanying cardiac event. If anything, COPD exacerbations can lead to increased troponin levels due to the strain on the heart.

Decreased Hematocrit Levels

Hematocrit (Hct) represents the proportion of red blood cells in the blood. In COPD, hematocrit is usually elevated due to polycythemia as a response to chronic hypoxia. A decreased hematocrit is more commonly associated with anemia, blood loss, or bone marrow disorders.

Summary:

In COPD, polycythemia is expected due to chronic hypoxia stimulating increased red blood cell production. Patients are more likely to have respiratory acidosis rather than alkalosis, troponin levels are typically unaffected unless there's heart involvement, and hematocrit is usually elevated, not decreased.

The correct answer is D: Exhibits tangential thinking.

Explanation:

Tangential thinking is characterized by a pattern of speech where the person starts on a topic but goes off track and does not come back to the original point. In the example, the client jumps from one thought to another without maintaining a logical connection, indicating tangential thinking.

Why the other options are incorrect:

A: Displays the use of word salad: Word salad refers to a jumble of words or phrases that are mixed up, making it nearly impossible to understand the meaning. The client's speech is not a jumbled mess of unrelated words, so this is incorrect.

B: Demonstrates thought-blocking: Thought-blocking occurs when a person abruptly stops talking or loses their thought in the middle of a conversation. This was not described in the client's speech, so this option is not correct.

C: Uses incoherent speech: Incoherent speech would imply that the person’s speech is completely disconnected or nonsensical. While the client’s speech is somewhat disorganized, it still contains understandable thoughts, so this option doesn't fit.

Summary:

The client’s speech is a good example of tangential thinking, where the person’s thoughts veer off topic without staying focused on the initial point. The correct documentation should reflect this.

The most appropriate approach in this situation would be:d. Approach her slowly while speaking in a calm voice, calling her name, and telling her that the nurse is here to help her

Rationale:

When dealing with a patient who is at risk of self-harm, such as this individual with wrist lacerations, the primary goals are to ensure the patient's safety, de-escalate the situation, and provide support. Here’s why option d is the best approach:

Calm and Reassurance: Approaching the patient slowly and calmly while speaking in a soothing voice helps in minimizing any anxiety or fear the patient might be experiencing. It also establishes a sense of trust and safety, which is essential in such a crisis situation. The patient may feel overwhelmed or frightened, and a calm, non-threatening approach can help alleviate this.

Active Listening and Presence: By calling her name and telling her that you are there to help, you are showing empathy and giving the patient an opportunity to engage in the situation. Engaging with the patient verbally helps to keep her grounded and reassured that she is not alone.

Safety First: While the patient is in a vulnerable state (bleeding from self-inflicted lacerations), your first priority should be to ensure her immediate safety and avoid further injury. You do not want to startle or upset her further. By introducing yourself calmly, you avoid escalating the situation.

Why the Other Options Are Not Ideal:

a. Enter the room quietly and move beside her to assess her injuries:

While assessing her injuries is important, this approach doesn’t prioritize building rapport with the patient or ensuring emotional safety before proceeding. A sudden or abrupt approach could feel threatening to the patient, and you would risk escalating the situation without first calming her.

b. Call for staff back-up before entering the room and restraining her:

While safety precautions are important, restraint should not be the first step in a situation like this unless the patient is in imminent danger of harming herself or others. The initial response should focus on verbal de-escalation and ensuring emotional safety. Calling for back-up and restraint can lead to further anxiety and potentially harm the therapeutic relationship.

c. Move as much glass away from her as possible and sit next to her quietly:

It’s important to remove dangerous objects (such as glass), but you should not focus solely on physical actions like moving the glass. The first priority is to engage the patient emotionally and offer immediate verbal support. Physical safety (removing glass) is important, but emotional safety should come first.

Key Takeaways:

Emotional de-escalation is critical when interacting with a patient in crisis. Approach the patient slowly and calmly, introduce yourself, and offer help before any physical action. Avoid jumping straight to restraints or physical actions before verbal and emotional engagement. Always ensure the patient’s safety while providing support and reassurance during the crisis.

Correct Answer: Serotonin Syndrome

Explanation:

This patient likely developed serotonin syndrome, a life-threatening condition caused by excess serotonin activity in the central nervous system. The key risk factor in this case is the recent use of phenelzine (a monoamine oxidase inhibitor, MAOI) followed by the initiation of venlafaxine (a serotonin-norepinephrine reuptake inhibitor, SNRI).

MAOIs inhibit the breakdown of serotonin, leading to increased serotonin levels.

Venlafaxine increases serotonin reuptake inhibition, further raising serotonin levels to dangerous levels when started too soon after an MAOI

Serotonin syndrome symptoms include:

Autonomic instability (e.g., tachycardia, diaphoresis, hypertension, hyperthermia)

Neuromuscular abnormalities (e.g., myoclonus, hyperreflexia, tremor, rigidity)

Mental status changes (e.g., agitation, confusion)

Why Other Options Are Incorrect:

Akathisia

A movement disorder characterized by inner restlessness, inability to sit still, and agitation. It is not associated with autonomic instability, hyperreflexia, or myoclonus, which are seen in serotonin syndrome.

Opisthotonos

A rare condition characterized by severe muscle spasms causing backward arching of the neck and spine. Seen in tetanus and severe neurological disorders, but not typical of serotonin syndrome.

Neuroleptic Malignant Syndrome (NMS)

A life-threatening reaction to antipsychotic drugs (e.g., haloperidol, risperidone). Symptoms include hyperthermia, autonomic instability, lead-pipe rigidity, and altered mental status, but does not involve myoclonus or hyperreflexia, which are characteristic of serotonin syndrome.

Summary:

The patient developed serotonin syndrome due to starting venlafaxine too soon after stopping phenelzine (an MAOI). The key symptoms—tachycardia, diaphoresis, myoclonic jerks, and autonomic instability—strongly indicate serotonin syndrome. The correct approach would be immediate discontinuation of serotonergic drugs, supportive care, and possibly administration of cyproheptadine (a serotonin antagonist) if symptoms are severe.

Correct Answer: B. "The other nurses and I are here to help you get better."

Rationale:

This response maintains professional boundaries and helps counteract the client's tendency for splitting, a common defense mechanism in borderline personality disorder (BPD) where the client sees others as all good or all bad. It reinforces that the entire healthcare team is working toward their well-being, rather than feeding into favoritism or emotional dependency.

Why Other Options Are Incorrect:

A. "You don't think the other nurses care about you?" This response is too open-ended and could encourage the client to reinforce their splitting behavior by further criticizing other staff members. It does not set clear boundaries.

C. "I am not the best nurse. All the nurses are good." While it attempts to correct the client's perception, it does not redirect the conversation toward a therapeutic goal or reinforce the role of the team in providing care.

D. "I do care about you as a person but nothing more." This response is unnecessary and could be misinterpreted by the client, leading to further emotional distress or manipulation. It does not address the splitting behavior effectively.

Summary:

The best approach in managing clients with BPD is to maintain consistency, set clear boundaries, and reinforce a team-based approach to care. Option B effectively addresses these principles without reinforcing splitting or dependency.

Correct Answer:  Rewarding positive behaviors to promote their recurrence.

Explanation

Positive reinforcement is a behavioral technique that increases the likelihood of a behavior recurring by rewarding desired actions. Example: If a child completes their homework, praising them or giving a small reward reinforces the behavior, making them more likely to repeat it. This technique is widely used in behavioral therapy, parenting strategies, and cognitive-behavioral interventions.

Explanation of Incorrect Answers:

"Agreeing with the child's statements, whether negative or positive, and simply restating the child's statements without other comment."

This is active listening, not positive reinforcement. While validating emotions is important, reinforcement requires an actual reward (praise, privilege, or tangible reward).

"Controlling the child's behavior, so there is no chance of negative behavior."

Over-controlling the child does not teach self-regulation and may lead to rebellion or dependence on authority. Positive reinforcement teaches the child to make good choices independently.

"Removing adverse consequences to produce positive results."

This describes negative reinforcement, not positive reinforcement. Negative reinforcement strengthens behavior by removing an unpleasant stimulus (e.g., letting a child skip chores if they complete homework). Positive reinforcement is about adding rewards, not removing consequences.

Summary:

The most effective technique is rewarding positive behaviors, as it reinforces good behavior patterns and increases their frequency. Over-controlling, passive agreement, or focusing on negative reinforcement does not achieve the same long-term behavioral benefits.

Correct Answer: D - Silence allows the client to reflect on what was said.

Rationale:

Therapeutic silence is a key communication technique in nursing that gives the client space to process their emotions and thoughts. In this case, the client has expressed deep emotional distress, and by remaining silent, the nurse allows them to reflect on their feelings and continue expressing themselves without interruption. This encourages the client to explore their thoughts more deeply, which can be therapeutic.

Why the Other Options Are Incorrect:

A - "The nurse is respecting the client's loss."

While respecting the loss is important, silence is not necessarily about respect—it is more about creating space for the client to process their feelings. A more active way to show respect would be through empathetic responses or gentle prompts.

B - "The nurse is showing disapproval of the statement."

Silence does not indicate disapproval; rather, it is a therapeutic tool to encourage the client to continue expressing their emotions. If the nurse were disapproving, they might change the subject or provide a dismissive response instead of using silence.

C - "Silence is reflecting the client's sadness."

While silence can create a somber atmosphere, it does not actively reflect the client’s emotions in the way that verbal acknowledgment or empathetic statements would. Silence is used to facilitate deeper reflection rather than just mirroring emotions.

Summary:

Using silence in this situation provides the client with time and space to reflect on their emotions and continue expressing their grief. This approach encourages deeper self-exploration and helps build a trusting therapeutic relationship.

Correct Answer: D - Escort the client from the group to reduce stimuli.

Rationale:

When a client is experiencing severe anxiety, they may become overwhelmed, have difficulty focusing, and be unable to process information effectively. The priority intervention is to reduce environmental stimuli and provide a calm, quiet space.

"Escort the client from the group to reduce stimuli" is correct because:

Severe anxiety can impair the client’s ability to participate in therapy.

Removing the client from a stimulating group setting can help them regain composure.

A quiet, less stressful environment allows for better emotional regulation.

Why the Other Options Are Incorrect:

A: Assist the client with relaxation techniques in the group 

Relaxation techniques are more effective for mild to moderate anxiety. A client in severe anxiety may not be able to focus on such techniques in a group setting.

B: Provide education about ways to cope with anxiety 

Clients in severe anxiety cannot process new information effectively. Education is better suited for mild or moderate anxiety levels.

C: Ask the client to describe and identify the source of the feelings 

Clients with severe anxiety struggle with verbalizing their emotions. This approach is more appropriate when the client is calmer.

SUMMARY:

 Escort the client from the group to reduce stimuli is a priority is reducing environmental stress and helping the client regain control.