MENTAL HESI 4 (EXAM QUESTIONS AND RATIONALES)
1. A woman admitted to the Emergency Department is bleeding profusely from a patch where hair was lost
... [Show More] from her scalp. She is accompanied by her husband who tells the nurse that his wife caught her hair on the railing and pulled it out when she fell down the stairs. The husband is solicitous of his wife and quickly answers questions on her behalf. He attempts to comfort his wife by saying to her, "I am right here with you, dear. Nothing can keep us apart." What is the priority nursing intervention?
A. Notify the local police of a suspected spousal abuse situation.
B. Ask the hospital security to remove the husband from the treatment room.
C. Reassure the husband that his wife will be treated well while he is in the waiting area.
D. Require the husband to leave the cubicle while the client is being treated. Correct
This client should be questioned about the possibility of spousal abuse and cannot answer truthfully in the presence of the perpetrator, so separating the couple is a priority, and (D) is the best method of providing this separation. (A) is not the priority at this time, and permission to notify the police should be obtained from the client. (B) is premature. Abusive husbands are unlikely to respond to manipulation (C) and are also unlikely to leave based on reassurances alone.
2. While assessing a 70-year-old male client, a nurse working in the outpatient clinic notices bruises on the client's chest. The client admits that his daughter, who is his caregiver, becomes frustrated and sometimes hits him. What is the priority outcome for the elderly client who sustained the abuse?
A. Verbalizes an acceptance of health status.
B. Expresses his feelings of satisfaction with care. Correct
C. States that the frequency of abuse has decreased.
D. Describes the potential danger of his situation.
Abuse cessation should result in the client feeling satisfied with his care (B). (A) is not identified as an issue. Total abuse cessation is the goal, not (C). (D) is of lesser importance than satisfaction with care.
3. The nurse is assessing a client who is believed to have a borderline personality disorder. Which question is most important to include in this assessment?
A. At what age did you begin to exhibit symptoms?
B. Do you have a family history of borderline disorder?
C. How often do you drink alcoholic beverages?
D. Do you frequently have temper tantrums? Correct
Those with a borderline personality disorder demonstrate intense outbursts of anger, so (D) is the most important question to ask. (A, B, and C) provide worthwhile information, but do not [Show Less]