Question

A client with schizophrenia receives a prescription for fluphenazine. Which instruction is most important for the nurse to include when teaching the client about this drug?

Answer 1

Correct Answers:

Notify your healthcare provider immediately if involuntary movements develop.

Rationale :

⚠️Fluphenazine, a first-generation antipsychotic, carries a high risk for extrapyramidal symptoms (EPS), including tardive dyskinesia.

👅Involuntary movements, such as lip-smacking, tongue thrusting, and facial grimacing, can become irreversible if not addressed promptly.

📞Immediate reporting allows the provider to modify or discontinue the medication before long-term damage occurs.

📘This teaching emphasizes safety and early intervention for potentially serious side effects.

📌Core Message

Report involuntary movements immediately to prevent irreversible extrapyramidal side effects.

Answer 2

Correct Answers:

Initiate short, frequent contacts with the client.

Rationale :

🤝Clients with delusional disorder often feel suspicious and threatened, making trust-building a slow process.

🕰️Short, frequent, and predictable interactions help create consistency, reduce anxiety, and build rapport over time.

🧠Confronting delusions directly or offering to take belongings may worsen paranoia and reduce trust.

📘This approach demonstrates therapeutic use of self while respecting the client's reality.

📌Core Message

Use brief, regular contact to foster trust with paranoid or delusional clients.

Answer 3

Correct Answers:

Teach the client to develop a plan for daily structured activities.

Rationale :

📅Clients with psychomotor retardation and amotivation benefit from structured, goal-directed routines to increase activity and engagement.

🧠Structured daily planning helps bypass executive function deficits common in major depressive disorder.

🏃‍♂️It provides a sense of accomplishment, which can counter low mood and build momentum for recovery.

📘Unlike general encouragement, teaching a plan gives the client a tangible framework to follow.

📌Core Message

A daily structured plan supports motivation and functional recovery in depression.

Answer 4

Correct Answers:

Reduce the noise level in the room by turning off the television and radio.

Rationale :

🔇Minimizing distractions creates a safe, calming environment that improves client focus and therapeutic engagement.

🧠A quiet space reduces sensory overload, particularly for anxious or paranoid clients.

📘This sets the tone for effective communication and builds a foundation for trust.

📋Physical proximity, lighting, and furniture should all support emotional safety and comfort without being intimidating.

📌Core Message

Low-stimulus environments improve client comfort and communication during mental health interviews.

Answer 5

Correct Answers:

Serum creatinine.

Rationale :

🩺Lithium is excreted entirely by the kidneys, so baseline renal function must be assessed to prevent toxicity.

🧪Serum creatinine evaluates kidney function and helps determine if the client can safely metabolize and eliminate lithium.

⚠️Impaired renal function increases the risk for lithium buildup, which can cause tremors, confusion, and even seizures.

📘This lab value is more directly related to lithium safety than liver or glucose monitoring.

📌Core Message

Check serum creatinine to assess kidney function before initiating lithium therapy.

Answer 6

Correct Answers:

Observe her actions continuously.

Rationale :

⚠️A sudden improvement in mood in a previously despondent client can signal increased suicide risk due to gained energy to act.

👁️Continuous observation ensures immediate intervention if self-harm behaviors emerge.📘Other interventions like group therapy or praising behavior may be appropriate later but are not the priority at this stage.

🧠Close monitoring during this shift in behavior protects the client during a critical safety window.

📌Core Message

Sudden mood improvement in depression can signal suicide risk—continuous observation is vital.

Answer 7

Correct Answers:

Abnormal Involuntary Movement Scale (AIMS).

Rationale :

🧠The AIMS tool is designed to assess for tardive dyskinesia and other movement disorders caused by psychotropic drugs.

👅Symptoms like tongue thrusting and hand movements are classic signs of this drug-induced condition.

📘Reviewing the AIMS documentation helps guide treatment adjustments and prevent progression.

📋This is more relevant than medical history or drug screens in identifying long-term medication effects.

📌Core Message

Use the AIMS scale to assess for tardive dyskinesia in clients on psychotropics.

Answer 8

Correct Answers:

Perform the dressing change in a non-judgmental manner.

Rationale :

👩🏻‍🤝‍🧑🏿Clients with borderline personality disorder often engage in self-harm to manage emotional pain and test limits.

🧘Providing care without judgment reduces shame and encourages therapeutic engagement.

📘The focus should be on physical care while modeling emotional neutrality and acceptance.

📋Asking “why” may sound accusatory and reinforce negative behaviors or attention-seeking cycles.

📌Core Message

Use a non-judgmental approach to support healing and build trust with self-harming clients.

Answer 9

Correct Answers:

Becomes the faculty sponsor for Students Against Drunk Driving (SADD).

Rationale :

🎓Taking on a proactive role in advocacy demonstrates constructive coping and transformation of grief into purpose.

🧠This action reflects healthy processing of trauma and aligns behavior with personal values.

📘Rather than avoiding the issue or focusing on the past, the client is channeling energy into positive change.

📋This is the most concrete indicator that the client is coping effectively with loss.

📌Core Message

Engaging in advocacy roles signals effective coping and recovery from emotional trauma.

Answer 10

Correct Answers:

Encourage activities that allow the client to exert control over the client's environment.

Rationale :

🧠Clients who experience multiple losses often feel powerless, so restoring a sense of control is vital for emotional recovery.

🎮Encouraging small, manageable tasks helps rebuild autonomy and self-confidence.

📘Avoiding upsetting topics or isolating the client can increase helplessness and prolong depression.

📋Helping the client regain control over their surroundings fosters resilience and stability.

📌Core Message

Support recovery by increasing the client’s control over their environment and choices.

HESI nur2520 psychiatric nursing Exam-2

No.

1 :
A client with schizophrenia receives a prescription for fluphenazine. Which instruction is most important for the nurse to include when teaching the client about this drug?

2 :
The mental health nurse observes that a female client with delusional disorder carries some of her belongings with her because she believes that others are trying to steal them. Which nursing action will promote trust?

3 :
A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and amotivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?

4 :
The nurse is preparing the physical environment to interview a new client for admission to the mental health unit. Which environmental setting facilitates the best outcome of the interview?

5 :
The healthcare provider prescribes lithium carbonate for a client diagnosed with bipolar, manic depression. It is most important for the nurse to review which laboratory finding prior to beginning the drug therapy?

6 :
After several days of being despondent and nonverbal, a female client with depression begins to talk and exhibit energy. Which action should the nurse implement?

7 :
When assessing a client who takes psychotropic medications, the nurse notes that the client has uncontrollable hand movements and is excessively protruding the tongue. Which assessment in the client's record should the nurse review?

8 :
The nurse is providing care for a client diagnosed with a borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the nurse use when changing this client's dressings?

HESI nur2520 psychiatric nursing Exam-2

No.

1 : A client with schizophrenia receives a prescription for fluphenazine. Which instruction is most important for the nurse to include when teaching the client about this drug?

2 : The mental health nurse observes that a female client with delusional disorder carries some of her belongings with her because she believes that others are trying to steal them. Which nursing action will promote trust?

3 : A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and amotivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?

4 : The nurse is preparing the physical environment to interview a new client for admission to the mental health unit. Which environmental setting facilitates the best outcome of the interview?

5 : The healthcare provider prescribes lithium carbonate for a client diagnosed with bipolar, manic depression. It is most important for the nurse to review which laboratory finding prior to beginning the drug therapy?

6 : After several days of being despondent and nonverbal, a female client with depression begins to talk and exhibit energy. Which action should the nurse implement?

7 : When assessing a client who takes psychotropic medications, the nurse notes that the client has uncontrollable hand movements and is excessively protruding the tongue. Which assessment in the client's record should the nurse review?

8 : The nurse is providing care for a client diagnosed with a borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the nurse use when changing this client's dressings?

1 :
A client with schizophrenia receives a prescription for fluphenazine. Which instruction is most important for the nurse to include when teaching the client about this drug?

2 :
The mental health nurse observes that a female client with delusional disorder carries some of her belongings with her because she believes that others are trying to steal them. Which nursing action will promote trust?

3 :
A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and amotivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?

4 :
The nurse is preparing the physical environment to interview a new client for admission to the mental health unit. Which environmental setting facilitates the best outcome of the interview?

5 :
The healthcare provider prescribes lithium carbonate for a client diagnosed with bipolar, manic depression. It is most important for the nurse to review which laboratory finding prior to beginning the drug therapy?

6 :
After several days of being despondent and nonverbal, a female client with depression begins to talk and exhibit energy. Which action should the nurse implement?

7 :
When assessing a client who takes psychotropic medications, the nurse notes that the client has uncontrollable hand movements and is excessively protruding the tongue. Which assessment in the client's record should the nurse review?

8 :
The nurse is providing care for a client diagnosed with a borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the nurse use when changing this client's dressings?