HESI RN MENTAL HEALTH
While in group therapy, a client who is diagnosed with posttraumatic stress disorder (PTSD) is processing
an experience from the
... [Show More] war in Iraq when another client tips over a chair. What action should the nurse
take when the client with PTSD falls to the floor in a fetal position?
A.
Confront the client who tipped over the chair about the inconsiderate behavior.
B.
Dismiss the other clients from the group therapy session for a 10-minute break.
C.
Reinforce reality to the client on the floor and remove him to a quiet space.
D.
Call a security code and medicate both clients with an antianxiety drug.
Correct Answer: C
Rationale:
The client who is diagnosed with PTSD is reexperiencing the traumatic experience and needs reality
reassurance (confirmation that there is no danger at this time) and reduced stimuli (C). (A, B, and D) do
not consider the needs of these two clients at this time.
The nurse notes multiple burns on the arms and chest of a 2-year-old Vietnamese child who is being
treated for dehydration. When questioned, the child's father states that he treated the child's vomiting
with the cultural practice termed coining, which resulted in burned areas. Which expected outcome
statement has the highest priority?
A.
The child will be protected from further harm.
B.
The family's cultural values will be respected.
C.
The parents will express regret at harming their child.
D.
The parents will demonstrate an ability to care for burn wounds.
Correct Answer: A
Rationale:
The nurse's highest priority is to ensure that no further harm befalls the child (A). (B, C, and D) are also
important objectives but are secondary to (A).
A client in an acute care facility has been taking antipsychotic medications for the past 3 days with a
decrease in psychotic behaviors and no adverse reactions. On the fourth day, the client experiences an
increase in blood pressure and temperature and demonstrates muscular rigidity. Which action should
the nurse initiate [Show Less]