HESI EXIT EXAM 2 A nurse on the psychiatric unit of the hospital has been assigned four clients for the
shift. The assignment includes an
... [Show More] 84-year-old client who is severely depressed, a 73-
year-old client who is being discharged, a 53-year-old client who was admitted for
lithium toxicity, and a 48-year-old client who has panic attacks. Which client should
the nurse evaluate first after receiving report?
1
84-year-old client
2
73-year-old client
Correct3
53-year-old client
4
48-year-old client
The 53-year-old client should be evaluated first because of the severity of adaptations
associated with lithium toxicity. A severely depressed client has a low energy level and is
not at the greatest risk at this time. A client who is stable enough to be discharged does not
need immediate attention. Clients with panic attacks usually seek immediate attention
when it is needed.
A young female client admitted to the trauma center after being sexually assaulted
continues to talk about the rape. Toward what goal should the primary nursing
intervention be directed?
1
Getting her involved with a rape therapy group
2
Remaining available and supportive to limit destructive anger
3
Exploring her feelings about men to promote future relationships
Correct4
Providing a safe environment that permits the ventilation of feelings
The client needs to be able to express her current feelings. Providing an environment in
which she feels safe will encourage this expression of feelings. It is too soon after the
assault to discuss this topic in a group. Although the nurse should be available and
supportive, feelings of anger are usually not the initial response. It is too soon after the
assault to discuss her feelings about men and future relationships.
A client is dying. Hesitatingly, his wife says to the nurse, "I'd like to tell him how
much I love him, but I don't want to upset him." Which is the best response by the
nurse?
1
"You must keep up a strong appearance for him."
2
"I think he'd have difficulty dealing with that now."
3
"Don't you think he knows that without your telling him?"
Correct4
"Why don't you share your feelings with him while you can?"
It is difficult to work through a loss; however, encouraging the sharing of feelings helps
both parties to feel better about having to let go. The response "You must keep up a strong
appearance for him" impedes the work of acceptance of one's finality and the use of the
remaining time to the best advantage. There is no evidence to suggest that the client cannot
cope with these emotions; the response "I think he'd have difficulty dealing with that now"
denies that this is a time for closeness and honesty. The response "Don't you think he
knows that without your telling him?" is demeaning, closes off communication, and does
not foster the expression of feelings.
A nonviolent client on the psychiatric unit suddenly refuses to take the prescribed
antipsychotic medication. What should the nurse do?
Correct1
Honor the client's decision and document the behavior and all interventions
2
Use an authoritarian approach to induce the client to take the prescribed medication
3
Call the health care provider and request that the client be discharged against medical
advice
4
Start proceedings to have the client declared incompetent and seek a court order
permitting medication
A client has the right to refuse treatment and should not be forcibly medicated unless the
client is deemed dangerous to him- or herself or others. An authoritarian approach is not
therapeutic and may compromise the nurse-client relationship. Calling the health care
provider is premature; first the nurse should attempt therapeutic interventions to meet the
client's needs. Starting proceedings to have the client declared incompetent is appropriate
for a client who is considered to be dangerous to him- or herself or others, or incompetent [Show Less]