MENTAL HESI 3 (Latest Update) (A Graded) Latest Questions and Complete Solutions
1. A 13-year-old female client is admitted to the Emergency Department
... [Show More] because she reports being raped. When the male unlicensed assistive personnel (UAP) enters the room to obtain her vital signs, she begins screaming for her mother and curls up in the corner of the room. What action should the nurse implement?
A. Reassure client that the male UAP is a staff member who wants to help her.
B. Tell the client that her fear is understandable under these circumstances.
C. Reassign an all-female healthcare team to the client until her fear subsides. Correct
D. Ask her mother to please stay with her throughout the assessment procedures.
A traumatized client needs to be in a non-threatening environment, and reassigning this client to all-female personnel is likely to reduce her anxiety (C). (A) is negating her fear. While validating the client's feeling (B) is important, this statement does not specifically address the client's issue with the male UAP. (D) might be helpful, but it ignores the anxiety the client feels about the presence of a male UAP.
2. At the end of a group therapy session, a client who is hospitalized for psychosis falls to the floor when attempting to stand. What intervention should the nurse implement first?
A. Ask a group member to seek help. Correct
B. Obtain the client's blood pressure.
C. Position in a recovery position.
D. Assess the client's level of orientation.
First, help should be obtained while the nurse remains with the client (A). Next, assessment of the client (B and D) should be completed. Lastly, the client should be positioned (C) to prevent aspiration while recovering.
3. The nurse is planning care for a female client with depression who cries when asked to make her menu selections. Which therapy group is likely to be most beneficial for this client?
A. Coping skills. Correct
B. Physical exercise.
C. Grief management.
D. Social support.
Ineffective coping skills (A) are characteristic of depression, and based on this client's symptoms, group therapy that focuses on coping skills is likely to be most beneficial. (B, C, and D) are important groups, but they are less likely to be as beneficial as (A).
4. The nurse is planning care for a client with major depression who is admitted to the unit after a recent suicide attempt. Which intervention has the highest priority for inclusion in this client's plan of care?
A. Search the client's personal belongings. Correct
B. Introduce the client to others on the unit.
C. Ask the client about recent stressful events.
D. Move to a room that allows close observation. [Show Less]