MENTAL HESI TEST 4 QUESTIONS &ANSWERS WITH RATIONALE_LATEST,100% CORRRECT

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A woman admitted to the Emergency Department is bleeding profusely from a patch where hair was lost 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. 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. C. States that the frequency of abuse has decreased. D. Describes the potential danger of his situation. 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? 4. A nurse is teaching a female client who is in a homosexual relationship about women's health. Which topic is the most important for the nurse to address? A. Sexually transmitted diseases. B. Annual gynecologic examination. C. Monthly breast self-examination. D. Domestic violence interventions. 5. A client who abuses alcohol says to the nurse, I am glad I went in for treatment. Now my problems with alcohol are all behind me. Which response is best for the nurse to provide? A. Yes, the treatment program you attended has an excellent success profile. B. Can you tell me more about what you mean when you say that your problems with alcohol are now behind you? C. You are likely to have a difficult time staying sober if you think that your problems with alcohol are behind you. D. Do you know what 'one day at a time' means for those who have problems with alcohol? 6. A male client who is on the liver transplant list is called to the unit for a possible transplant. When learning that the donor organ is no longer available, the client slams doors and shouts vulgarities about his situation. What action should the nurse implement first? A. Encourage him to share his feelings more appropriately. B. Express concern over his disappointment. C. Arrange to have a clergy person visit. D. Administer a PRN prescription for an antianxiety drug. . 7. A client is told that her infant will be stillborn. What is the most important action for the nurse to implement after the birth? A. Ask the family if they would like to see and hold the infant after birth. B. Inquire if the parents want a picture taken after the infant is born. C. Discuss with the parents which funeral home should be notified. D. Find out if the client has a special outfit for the infant after the birth. 8. A client who has a miscarriage at 10-weeks gestation tells the nurse that she already purchased some baby things and picked out a name. After the surgical dilation and curettage (D&C), the client wants to go home as soon as possible. Based on the client's statements, which action should the nurse implement? A. Ready the client for discharge. B. Notify pastoral care to offer the client a blessing. C. Ask the client what name she had picked out for the infant. D. Inquire if the client would like to see what was obtained from her D&C. 9. Which nursing intervention should the nurse implement with parents who experience a fetal demise and express the wish not to see the baby? A. Tell them there is nothing to fear. B. Insist that they hold infant so they can grieve. C. Respect their wishes and release the body to the morgue. D. Keep the body available for a few hours in case they change their minds. 10. A client actively involved in substance addiction therapy frequently relapses into benzodiazepines and alcohol use. The client tells the nurse, I don't think I will ever be able to kick this habit. How should the nurse respond? A. The goal of the individual is one of growth, health, autonomy, and self-actualization. B. All people have the right to an equal opportunity for adequate health care. C. Dependence on an extensive support system is needed to overcome any addiction. D. The client must participate in making decisions about his/her own physical and mental health. 11. A client who is admitted with the chief complaint of feeling depressed tells the nurse, I want to feel normal again. How should the nurse respond? A. How long have you felt this way? B. We are all here to help you get better. C. What do you think the hospital can do for you? D. Tell me more about how things are with you. 12. The nurse is planning the care for a client based on the psychoanalytical model. Which intervention should the nurse include? A. Emphasize the client's strengths and assets. B. Teach the importance of medication compliance. C. Offer the client psychoeducational materials to read. D. Focus on the client's positive or negative feelings toward the nurse. 13. A female client responds to the nurse with negative comments and antagonistic behavior. The nurse tells the client that she is unconsciously casting the nurse in the role of the client's mother. The nurse's feedback is based on which model of therapy? A. Medical. B. Existential. C. Interpersonal. D. Psychoanalytical. 14. Which client should the nurse identify as the highest risk for the onset of stress-related problems? A. A man whose new business is growing slowly, who plans to adopt a child with his wife, and says, I think I'm in control of my destiny. B. A woman who is graduating from college, getting married in one month, and states, I'm anticipating the changes these events will make in my life. C. A client who is passed over for promotion, quits a job to start a new business, and states, This is just one of a series of challenges I've faced in my life. D. A person whose father died three months ago, who is losing a job due to company downsizing, and states, Living with loss and the threat of loss makes me feel helpless. 15. The client with depression asks the nurse, What are neurotransmitters? My doctor thinks my problem may lie with the neurotransmitters in my brain. What information should the nurse use to support an explanation of neurotransmitters? A. Chemical messengers that cause brain cells to turn on or off. B. Areas of the brain that are responsible for controlling emotions. C. Clumps of cells that alert the other brain cells to receive messages. D. Web-like structures that provide connections among parts of the brain. 16. A client is scheduled to complete a positron emission tomography (PET) scan. The client asks the nurse to explain the reason the test was prescribed. How should the nurse respond? A. Images indicate the presence of tumors and scars. B. The scan clearly outlined structures of the brain. C. Results show activity in various portions of the brain. D. PET shows biochemical levels of neurotransmitters. . 17. A client with panic disorder tells the nurse, This illness is awful. I'm frightened that I will always be this way and that there's no hope for me. What is the best information for the nurse to provide? A. Panic disorder is treatable in a number of different ways, including medication. B. Understanding the fact that a cure is not attainable helps the client learn to adjust. C. This disorder is a biologically determined hereditary disease that has no cure. D. Evidence based practice indicates that neuroleptic drugs can be used prophylactically. 18. A female client who is admitted for treatment of uncontrolled diabetes mellitus is withdrawn and tearful. She complains she has gained excessive weight because she hates her diet, hates taking insulin, and just wants to be normal again. What therapeutic action should the nurse take? A. Assist the client in verbalizing distress about the disease. B. Inquire about emotional factors affecting the client's present condition. C. Assess priorities to be set for the client's overall nursing care plan. D. Encourage the client to emotionally accept the chronicity of the disease. 19. Which action is most important for the nurse to implement during the initial interview for a client who is admitted to the mental health unit? A. Establish rapport in each phase of the nurse-client relationship. B. Determine the client's ability to communicate effectively. C. Reflect on previous psychiatric interviews the nurse has performed. D. Ensure data is collected and recorded in a systematic sequence. 20. When assessing a client's emotional intelligence, which client capabilities should the nurse focus the interview on with a client diagnosed with a chronic mental illness? A. Linguistic and musical abilities. B. Interpersonal and intrapersonal skills. C. Bodily kinesthetic and spatial abilities. D. Logical mathematics and linguistic abilities. 21. A female client with severe depression is given information about the risks, benefits, alternatives, and expected outcomes of electroconvulsive therapy (ECT) and signs the informed consent for treatment. After the client's family leaves, the client tells the nurse, I signed the papers because my husband told me I will be deported if my depression is not cured. What information should the nurse report to the healthcare provider? A. The client's consent may have been coerced. B. All the elements of informed consent were met. C. The woman may not fully understand the risks and benefits. D. The client is not competent to sign permission for treatment. . 22. A male client tells the nurse that he plans to kill his spouse and her lover as soon as he is released from the hospital. What action should the nurse implement? A. Keep this information confidential until the client's release. B. Immediately contact the client's spouse and the lover. C. File oral and written reports with the local police department. D. Inform the healthcare provider and document the plan in the record. 23. A male client is brought to the emergency department by a police officer, who reports the client was disturbing the peace by running naked in the street, striking out at others, and smashing car windows. Which behaviors should the client demonstrate to determine if he should be evaluated for involuntary commitment? (Choose all that apply.) A. Threats to kill his friend. B. Disruptive behaviors in a community setting. C. Hears voices telling him to kill himself. D. Reports he has not needed a bath in 4 months. E. Created extensive private property damage. F. Says he has not eaten in 3 days. 24. What action should the nurse take when a client who is psychotic proposes goals that are both unrealistic and undesirable? A. Do nothing and remember the client's rights. B. Express doubt that the goal can be achieved. C. Tell the client that the goal is unrealistic. D. Reflect the client's behavior and its consequences. 25. A client is pacing in the hall near the nurses' station and swearing loudly. What response is best for the nurse to provide? A. Hey, what's going on? B. Others are being distracted. Please, quiet down. C. You seem pretty upset. Tell me about it. D. Please go to your room to get control of yourself. 26. A client is responding to auditory hallucinations and shakes a fist at a nurse and says, Back off, witch! The nurse follows the client into the day room. What action should the nurse implement? A. Sit down in a chair near the client. B. Position self within an arm's length of the client. C. Ensure that there is physical space between the nurse and client. D. Move to a position that allows the client to be closest to the room's door. 27. A male client with severe orthopedic injuries following a motor vehicle collision is irritable, angry, and belittles the nurses. While a nurse is changing the dressing over a laceration, the client screams, Don't touch me! You're so stupid that you'll make it worse! Which intervention is best for the nurse to implement? A. Leave the room without saying a word. B. Provide information about infection prevention. C. Allow the client to change the dressing himself. D. Explain the healthcare provider's prescription. 28. A 35-year-old married woman works full-time in a factory and has been absent from work for three days at a time on several occasions. Each time she returns to work, she wears dark glasses to cover facial bruising. Her supervisor refers her to the occupational health nurse. What assessment question is most important for the nurse to initially use? A. Do you drink excessively? B. Did your husband beat you? C. How did this happen to you? D. What did you do to deserve this? 29. A female client presents to the emergency center with confusion, emotional numbness, and expresses to the nurse a feeling of disbelief that she was raped. The nurse determines the client is in the acute phase of rape-trauma syndrome. What action should the nurse implement first? A. Secure samples of vaginal hair combings. B. Offer prophylactic antibiotic medication. C. Explain the rape protocol to the client. D. Implement crisis intervention counseling. 30. Which client outcome indicates improvement for a client who is admitted with auditory hallucinations? A. Argues with the voices. B. Tells when voices decrease. C. Follows what the voices say. D. Tells the nurse what the voices say. 31. The nurse is caring for an adult male client with catatonic schizophrenia who is mute and motionless. What is the priority nursing diagnosis? A. Impaired mobility. B. Ineffective individual coping. C. Impaired verbal communication. D. High risk for fluid and electrolyte imbalance. 32. A client with a history of alcoholism is admitted with a compound fracture of the femur after falling down the previous night. What additional assessment should be the priority focus for the nurse? A. Collect a specimen for a blood alcohol level (BAL). B. Do nothing because the time for BAL determination is passed. C. Review the results of a Breathalyzer obtained in the emergency department upon admission. D. Ask the client about the quantity, frequency, and time the last alcohol drink was ingested. 33. A client who is intoxicated is admitted for alcohol and multiple substance detoxification. The nurse determines that the client is becoming increasingly anxious, agitated, and diaphoretic. The client is also experiencing sensory perceptual disturbances and a clouded sensorium. What is the priority nursing intervention for this client at this time? A. Check on the client every 15 minutes. B. Begin one-on-one supervision immediately. C. Keep the room dimly lit and turn on the radio. D. Push fluids and provide calorie-rich nutritional supplements. 34. A female client comes to an outpatient therapy appointment intoxicated. The spouse tells the nurse, There wasn't anything I could do to stop her drinking this morning. What intervention should the nurse take at this time? A. Arrange for emergency admission to a detoxification unit. B. Talk to the spouse about strategies to limit the client's drinking. C. Have the client admitted to the inpatient psychiatric unit. D. Tell the client that therapy cannot take place while she is intoxicated. 35. Which client statement should the nurse identify as most typical of a client with mania? A. I can't do anything anymore. B. I can't understand where all our money goes. C. I manage our finances great because I buy in big quantities. D. I wonder why my wife is so upset that I spend money easily. 36. What nursing assessment is the priority focus for a client with major depression? A. Mood and affect. B. Suicidal ideation. C. Nutritional status. D. Fluid and electrolyte balance. 37. The nurse is caring for a client who received the first-time electroconvulsive therapy (ECT) a half hour ago. Which action should the nurse implement first? A. Offer oral fluids. B. Monitor vital signs. C. Evaluate ECT effectiveness. D. Encourage group participation. 38. A client with substance abuse is admitted to the mental health unit. Which action should be implemented by the nurse, and not delegated to a unlicensed assistive personnel (UAP)? A. Provide menus for dietary selections. B. Clarify visiting hours and telephone usage. C. Collect a complete substance abuse history. D. Obtain vital signs and orient the client to the unit. 39. Which action should the nurse implement first for a client experiencing alcohol withdrawal? A. Apply vest or extremity restraints. B. Give an alpha-adrenergic blocker. C. Provide a diet high in protein and calories. D. Prepare the environment to prevent self-injury. 40. The nurse is caring for a client who was admitted for alcohol detoxification 2 days ago. Which finding is most critical for the nurse to report to the healthcare provider? A. Restlessness, anxiety, and difficulty sleeping. B. Global confusion and inability to recognize family members. C. Agitation, vomiting, and visual and auditory hallucinations. D. Low-grade fever, diaphoresis, hypertension, and tachycardia. 41. During a one-to-one interaction, a male client describes the sadness he experienced when his mother died. Suddenly, the nurse begins to think about her grandmother's death. As a result, the nurse asked the client to describe his thoughts when he learned of his own mother's illness. What is the nurse doing? A. Reflection. B. Clarification. C. Self-Awareness. D. Focusing. 42. The community health nurse facilitates a substance abuse prevention group for a homeless population. Which statement demonstrates that a client has a realistic understanding of the recovery process? A. I do OK as long as I can get methadone from the clinic regularly. B. By learning what led to my latest relapse, I know what to do in the future. C. A 12-step program is the only treatment approach that is proven effective. D. I know now that I wasn't ready to make a change until I hit rock bottom. 43. A female client with bipolar disorder, manic phase, is planning weekend activities with the other clients on the unit. The client interrupts the group, insists that they change their plans to a disco party, and begins to curse loudly when the group refuses to change the plans. Which intervention should the nurse implement? A. Tell the client to quiet down. B. Escort the client to a quieter place. C. Ask the group to reconsider the suggestion. D. Ignore the client's manic outbursts. 44. Which action should the nurse implement during the termination phase of the nurse-client relationship? A. Identify new problem areas. B. Confront changes not completed. C. Explore the client's past in depth. D. Help summarize accomplishments 45. Which statement made by an adolescent in group therapy should the nurse identify as a priority in planning care? A. If I fail another class, I'm going to kill myself. B. I have a necktie in my room that I can use to hang myself. C. When I leave home to live on my own, I'm buying myself a gun. D. I took two bottles of Mom's pills and had to have my stomach pumped. 46. The nurse is caring for a female client who is admitted for depression with the nursing diagnosis, Self-esteem, chronic low. Which client response indicates to the nurse that the client has improved self-esteem? A. Identifies own strengths. B. Stops crying during every session. C. Talks with other clients about marital advice. D. Asks the nurse if her behavior has improved. 47. During an inpatient therapy group session, a client tells the members that he hears voices that say his doctor is going to poison him. He continues, "I look around to see who's talking to me, and I can't see anybody." Another client replies, "I used to hear voices, too. I found out they were my imagination. The voices you hear aren't real either." Which phenomenon, common to groups, is exemplified in this interchange? A. Catharsis. B. Ventilation. C. Universality. D. Reality testing. 48. An adolescent who attempted suicide with a drug overdose arrives in the emergency department with an empty 30-tablet bottle of acetaminophen (Tylenol). Which action should the nurse implement? A. Administer acetylcysteine (Mucocyst). B. Monitor cardiac rhythm for flat T waves. C. Check both serum AST and ALT levels. D. Prepare to administer Syrup of Ipecac. 49. A client on the mental health unit reports concerns about weight gain as a result of taking divalproex (Depakote) and requests assistance to fill out a menu. The nurse should initiate a referral to which healthcare team member? A. Occupational therapist. B. Recreational therapist. C. Dietician. D. Physician. 50. During the admission of a male client to the mental health unit, the client tells the nurse that he had a panic attack today and ran out of the physician's office. Which question is most important for the nurse to ask this client? A. On a scale of 1 to 10 how do you rate your anxiety level? B. How would you describe your mood right now? C. Have you had any thoughts of hurting yourself? D. What medications have you taken in the last 24 hours? 51. The daughter of a female client with stage-1 Alzheimer's disease (AD) asks the nurse what changes should she expect her mother to demonstrate in this stage. What finding should the nurse tell the daughter is common? A. Inability to recognize one's location. B. Personality changes and agitation. C. Depression and emotional lability. D. Alterations in communication. 15. A male client on a psychiatric unit becomes extremely agitated and begins to smash his head against doors. He seems frightened, and his verbalizations suggest he is experiencing distorted sensory perceptions. What action should the nurse take first? A. Place the client in mechanical restraints until calm. B. Administer a PRN dose of haloperidol (Haldol) IM. C. Use a calm, soothing voice to diffuse the situation. D. Encourage the client to focus on his feelings of anger. 16. During an admission assessment interview, a client states, "I do not use many drugs." How should the nurse respond? A. "Tell me about the drugs you use now." B. "Explain what you mean by many drugs." C. "Do you mean legal drugs or illegal ones?" D. "What kind of drugs are you talking about?" [Show More]

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