HESI MENTAL HEALTH RN V1-V3 2019 TEST BANKS (ALL TOGETHER),100% CORRECT

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A client with depression remains in bed most of the day, and declines activities. Which nursing problem has the greatest priority for this client? The RN is preparing medications for a client with bi... polar disorder and notices that the client discontinued antipsychotic medication for several days. Which medication should also be discontinued? A female client requests that her husband be allowed to stay in the room during the admission assessment. When interviewing the client, the RN notes a discrepancy between the client’s verbal and nonverbal communication. What action does the RN take? A male client approaches the RN with an angry expression on his face and raises his voice, saying “My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out!” The RN recognizes that the client is using which defense mechanism? A male client with bipolar disorder who began taking lithium carbonate five days ago is complaining of excessive thirst, and the RN finds him attempting to drink water from the bathroom sink faucet. Which intervention should the RN implement? The RN is teaching a client about the initiation of the prescribed abstinence therapy using disulfiram (Antabuse). What information should the client acknowledge understanding? A male client with schizophrenia is admitted to the mental health unit after abruptly stopping his prescription for ziprasidone (Geodon) one month ago. Which question is most important for the RN to ask the client? During an annual physical by the occupational RN working in a corporate clinic, a male employee tells the RN that is high-stress job is causing trouble in his personal life. He further explains that he often gets so angry while driving to and from work that he has considered “getting even” with other drivers. How should the RN respond? A client who has agoraphobia (a fear of crowds) is beginning desensitization with the therapist, and the RN is reinforcing the process. Which intervention has the highest priority for this client’s plan of care? Which nursing actions are likely to help promote the self-esteem of a male client with modern depression? A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of Risperidone (Risperdal). When the client walks to the nurse’s station in a laterally contracted position, he states that something has made his body contort into a monster. What action should the RN take? A mental health worker is caring for a client with escalating aggressive behavior. Which action by the MHW warrant immediate intervention by the RN? A client on the mental health unit is becoming more agitated, shouting at the staff, and pacing in the hallway. When the PRN medication is offered, the client refuses the medication and defiantly sits on the floor in the middle of the unit hallway. What nursing intervention should the RN implement first? A client is admitted to the mental health unit and reports taking extra antianxiety medication because, “I’m so stressed out. I just want to go to sleep.” The RN should plan one-on-one observation of the client based on which statement? A male hospital employee is pushed out the way by a female employee because of an oncoming gurney. The pushed employee becomes very angry and swings at the female employee. Both employees are referred for counseling with the staff psychiatric RN. Which factor in the pushed employee’s history is most related to the reaction that occurred? The RN documents the mental status of a female client who has been hospitalized for several days by court order. The client states, “I don’t need to be here” and tells the RN that she believes the television talks to her. The RN should document these assessment findings in which section of the mental status exam/ A client is admitted to the mental health unit reports shortness of breath and dizziness. The client tells the RN, “I feel like I’m going to die”. Which nursing problem should the RN include in this client’s plan of care? A female client who is wearing dirty clothes and has foul body odor, comes to the clinic reporting feeling scared because she is being stalked. What action is most important for the RN to take? The RN leading a group session of adolescent clients gives the members a handout about anger management. One of the male clients is fidgety, interrupts peers when they try and talk, and talks about his pets at home. What nursing action is best for the RN to take? A male adolescent was admitted to the unit two days ago for depression. When the mental health RN tries to interview the client to establish rapport, he becomes very irritated and sarcastic. Which action is best for the RN to take? A male adult is admitted because of an acetaminophen (Tylenol) overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client's discharge plan? After receiving treatment for anorexia, a student asks the school RN for permission to work in the school cafeteria as part of the school’s work study program. What action should the RN take? The Rn accepts a transfer to the metal health unit and understands that the client is distractible and is exhibiting a decreased ability to concentrate. The RN only has 15 minutes to talk to the client. To develop treatment plan for this client, which assessment is most important for the RN to obtain? A male client who recently lost a loved one arrives at the mental health center and tells the RN he is no longer interested is his usual activities and has not slept for several days. Which priority nursing problem should the RN include in the client’s plan of care? A male client with long history of alcohol dependency arrives in the emergency department describing the feelings of bugs crawling on his body. His blood pressure is 170/102, his pulse rate is 110 bpm, and is blood alcohol level is 0mg/dL. Which prescription should the RN administer? A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words and wanders into client’s rooms. The RN decides that the client needs constant observation based on which of these assessment findings? A client with schizophrenia explains that she has 20 children and then very seriously points to the RN and explains that she is one of them. What is the most therapeutic response for the RN to provide/ A high school girl reveals to the high school RN that she has been engaging in self-induced vomiting as weight-control measure. Which initial assessment should the RN focus on with this adolescent? Narcan was administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate (Vicodin). Within 15 minutes, the client is alert and oriented. In planning nursing care, which intervention has the highest priority at this time? Following surgery, a male client with antisocial personality disorder frequently requests that a specific RN be assigned to is care and is belligerent when another RN is assigned. What action should the charge RN implement? . When preparing to administer a prescribed medication to a homeless male at a community clinic, the client tells the RN that he usually takes a different dosage. What action should the RN take? The nurse orients a female client with depression to the new room on the mental health unit. The client states “It seems strange that I don’t have a T.V in my room.” Which statement would be best for the RN to provide? A client admitted with a closed head injury after a fall has a blood alcohol level of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the RN identify as the priority? The RN is completing the admission assessment of an underweight adolescent who is admitted to a psychiatric unit with a diagnosis of depression. Which finding requires notification to the HCP? The Rn is planning client teaching for a 35-year-old client with alcoholic cirrhosis. Which self-care measure should the RN emphasize for the client’s recovery? A teenager has lost 20 pounds in the last three months is admitted to the hospital with hypotension and tachycardia. The client reports irregular menses and hair loss. Which intervention is most important for the RN to include in the clients plan of care? While interviewing a client, the nurse takes notes to assist with accurate documentation later. Which statement is most accurate regarding note-taking during an interview? A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care? . A client who is being treated with lithium carbonate for manic depression begins to develop diarrhea, vomiting, and drowsiness. What action should the nurse take? While caring for an older client, the RN observes multiple bruises in Over the client’s legs, arms, back, and gluteal areas. When the client Contact, the RN suspects elder abuse. What action should the RN take? The RN is performing intake interviews at a psychiatric clinic. A female client with a known history of drug abuse reports that she had a heart attack four years ago. Use of which substance places the client at highest risk for myocardial infarction? After receiving treatment for anorexia, a student asks the school RN for permission to work in the school cafeteria as part of the school’s work study program. What action should the RN take? A client who is homeless is diagnosed with schizophrenia and admitted on an involuntary basis to a mental health hospital 4 days ago. The client stopped taking prescribed antipsychotic drugs approximately one month ago. Since hospitalization the client continues to have poor judgment and refuses all medications. What action should the RN take? A male client comes to the emergency center because he has an erection that will not resolve. The client reports that he is taking trazodone (Desyrel) for insomnia. Which information is most important for the nurse ask the client? On admission to the mental health unit, a client diagnosed with schizophrenia tells the RN that he is the son of god. Based on this statement, which intervention should the RN include in this client’s plan of care? The RN on the day shift receive report about a client with depression who was in bed most of the weekend. The RN walks into the client’s room in the morning and finds the client in bed. What intervention is best for the RN to implement? Which client information indicates the need for the RN to use CAGE questionnaire during the admission interview? . A female client admitted to the mental health unit starts to shout and scream at the RN. What is the best approach for the RN to take? A woman is brought to the psychiatric clinic by her husband. He reports that his wife is reluctant to leave home because of what she describes as a fear of open places and crowds. Which nursing problem applies to this client’s behavior? A client is receiving benztropinemesylate (Cogentin) for drug-induced extrapyramidal syndrome (EPS). Which finding indicates that the RN should further evaluate the client? A male client in the mental health unit is guarded and vaguely answers the nurse’s questions. He isolates in his room and sometimes opens the door to peek into the hall. Which problem can the RN anticipate? A female client with obsessive compulsive personality disorder is admitted to the hospital for a cardiac catheterization. The afternoon before the procedure, the client begins to keep detailed notes of the nursing care she is receiving, and reports her findings to the RN at bedtime. What action should the nurse implement? During admission to the psychiatric unit, a female client is extremely anxious and states that she is worried about the sun coming up the next day. What intervention is most important for the RN to implement during the admission process? A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The RN also determines that the client is homeless and is exhibiting suspiciousness. The client’s plan of care should include what priority problem? The occupational health nurse is working with a female employee who was just notified that her child was involved in a MVA and taken to the hospital. The employee states, “I can’t believe this. What should I do?” Which response is best for the RN to provide in this crisis? A client tells the RN that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. What is the priority nursing problem for admission to the psychiatric unit? The RN is providing care for a client diagnosed with borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the RN use when changing this client’s dressing? . While sitting in the day room of the mental health unit, a male adolescent avoids eye contact, looks at the floor, and talks softly when interacting verbally with the RN. The two trade places, and the RN demonstrates the client’s behaviors. What is the main goal of this therapeutic technique? An antidepressant medication is prescribed for a client who reports sleeping only 4 hours in the past 2 days and weight loss of 9 lbs within the last month. Which client goal is most important to achieve within the first three days of treatment? When preparing to administer to domestic violence screening tool to a female client, which statement should the RN provide? A young adult female visits the mental health clinic complaining of diarrhea, headache, and muscle aches. She is afebrile, denies chills, and all laboratory findings are within normal limits. During the physical assessment, the client tells the RN that her sister thinks she is neurotic and calls her a hypochondriac. Which response is best for the RN to provide? The RN is leading a group on the inpatient psychiatric unit. Which approach should the RN use during the working phase of group development? A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. What intervention is best for the RN to implement? A client is admitted for bipolar disorder and alcohol withdrawal, depressive phase. Based on which assessment finding will the RN withhold the clonidine (Catapres) prescription? The RN on the evening shift receives report that a client is scheduled for electroconvulsive treatment (ECT) in the morning. Which intervention should the Rn implement the evening before the scheduled ECT? . A client with Bulimia and depression who is taking phenelzine (Nardil) 90 mg daily is admitted to an acute care hospital for uncontrolled hypertension. What dietary choices should the RN instruct the client to avoid? A mental health worker is caring for a client with escalating aggressive behavior. Which action by the mental health worker warrants immediate intervention by the RN? A client who recently experienced the death of a significant other arrives at the mental health center. The client reports loss of interest in usual activities, expresses a wish to be with the decreased significant other, has been eating very little, and has not slept in several days. Which client statement is most important for the RN to explore at this time? A middle aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and motivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning? When developing a plan of care for a client admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing problem has the highest priority? A female client on a psychiatric unit is sweating profusely while she vigorously does push-ups and then runs the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbance, the client shouts, “I am the boss here. I do what I want.” Which nursing problem best supports these observations? A RN 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? An older homeless client visits the psychiatric clinic to obtain a prescription renewal for alprazolam (Xanax). During the health assessment, the client complains of chest pain. Which action should the RN take first? The mother of an 8-month-old infant with profound mental and physical disabilities tells he RN how depressed she is because she realized that her child will never achieve normal growth and development milestones. How should the RN respond to the mother? Several clients with chronic mental illness and multiple substance abuse histories live in a group residential home and attend daycare mental health facility where group and individual therapies are provided. The RN finds the common bathroom at the facility with sputum on the walls, urine in the sink and on the floors, and the toilet stopped up with tissue, paper towels, and feces. What is the priority issue that the RN should address? A client with schizophrenia is admitted to the psychiatric care unit for aggressive behavior, auditory hallucinations, and potential for safe harm. The client has not been taking medications as prescribed and insists that the food has been poisoned and refuses to eat. What intervention should the RN implement? The RN is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? (SOA) The RN is admitting a male client who take lithium carbonate (Eskalith) twice a day. Which information should the RN report to the HCP immediately? A male client who is admitted with delirium tremens is dehydrated and experiencing auditory hallucinations. He has a bruised, swollen tongue and is confused. In developing a plan of care, which action should the RN include to ensure the client is physiologically stable? A RN is teaching a client about initiation of a prescribed abstinence therapy using Disulfiram (Antabuse). What information should the client acknowledge understanding? The RN is working with a male client at a community mental health center when the client reports hearing voices that tell him to get a knife from the kitchen and hurt himself. What intervention is most important for the RN to implement? . A homeless client who reports feeling sad and depressed tells the mental health nurse that in the past 2 days she has only had 4 hours of sleep. Which action is most important for the RN to implement within the first 24 hours after treatment is initiated? Which client statement suggests the RN that the client is using a defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit? A male client is admitted to the psychiatric inpatient unit with a bandaged flesh wound after attempting to shoot himself. He was divorced one year ago. Lost his job four months ago, and suffered a breakup of is current relationship last week. What is most likely source of this client’s current feelings of depression? . The RN documents the mental status of a female client who has been hospitalized for several days by court order. The client states”I don’t need to be here,” and tells the RN that she believes that the t.v talks to her. The RN should document these assessment statements in which section of the mental status exam? An older ale client with schizophrenia is found smearing feces n the bathroom walls of the chronic mental health unit where he resides. What action should the RN implement? A male client tells the RN that he does not want to take the atypical antipsychotic drug, olanzapine (Zypexa), because of the side effects he experienced when he took the drug for a year. Which experience is most likely related to taking olanzapine? A college student who is a victim of a car-jacking presents to the community health center and report increased anxiety. During the interview, what nursing intervention should take the highest priority? The RN completes an assessment of a client who is experiencing intimate partner violence (IPV). Which finding of the injuries should the RN include in the documentation? . Following involvement in a MVC, a middle aged adult client is admitted to the hospital with multiple facial fractures. The client’s blood alcohol level is high on admission. Which PRN prescription should be administered if the client begins to exhibit signs and symptoms of delirium tremens (DTs)? Patient says “I'm going to shoot myself” A client who is known to abuse drugs is admitted to the psychiatric unit. Which medication should the nurse anticipate administering to a client who is exhibiting benzodiazepine withdrawal symptoms? A woman brings her 48-year-old husband to the outpatient psychiatric unit and describes his behavior to the admitting nurse. She states that he has been sleepwalking, cannot remember who he is, and exhibits multiple personalities. The nurse knows that these behaviors are often associated with which condition? Which diet selection by a depressed client taking tranylcypromine sulfate (Parnate), an MAO inhibitor, indicates to the nurse that the client understands the dietary restrictions imposed by this medication regimen? A female client on a psychiatric unit is sweating profusely while she vigorously does pushups and then runs the length of the corridor several times before crashing in to the furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbances, the client shouts," I am the boss here. I do what I want." Which nursing problem best supports these observations 8. A female client engages in repeated checks of door and window locks. Behavior that prevents her form arriving on time and interferes with her ability to function effectively. What action should the nures take? 9. The nurse is preparing medications for a client with disorder and notices that the antipsychotic medication was discontinued several days ago. Which medication should also be discontinued? 10. The nurse is teaching a client about the initiation of a prescribed abstinence therapy using disulfiram (Antabuse). What information should the client acknowledge understanding 11. A male client with bipolar disorder tells the nurse that he needs to "make some deals so that he can improve his retirement savings." Based on this information, which client outcome should the nurse include in the plan of care 12. teenaged girl self induced vomiting 13. Pt is getting oreiented to the unit and replies “there are no TVs in the room” What is the nurse’s best respond? 14. A male adult is admitted because of an acetaminophen (Tylenol) overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client's discharge plan? 15. The nurse documents the mental status of a female client who has been hospitalized for several days by court order, The client states, "I don't need to be here" and tells the nurse that she believes that the television talks to her. The nurse should document these assessment findings in which section of the mental status exam? 16. A client who has agoraphobia (a fear of crowds) is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care? 17. ECT therapy is not working, pt is non responsive to treatment what question should the nurse ask? 18. adolescent teen interrupts group about pets at home 19. depressed pt in bed all weekend, nuse finds pt still in bed on her shift, what is the best action to take? 20.postpartum depression Sign & Symptoms (3) 21.ECT pre treatment teaching 24. client who refuses antipsychotic medication disrupt group activities nurse decides client needs constant observation based on? 25. recurrent negative symptoms of chronic schizophrenia and medication risperdal. walks laterally contracted position, something has made his body contort 26. depression remains in bed most of the day, declines activities and refuses meals 27. Victim of intimate partner violence what 3 things should you do? SELECT ALL THAT APPLY (only 3 correct answers) 28. patient taking sertraline (zoloft) for postpartum depression, nursing teaching 29. client sitting in corner of day room during admission assessment, what nursing action 30. Psychomotor retardation, hypersomnia, and amotivation; what nursing intervention? 31. Client makes a statement I feel like im going to die, what level of Anxiety is it? 32.TOOL assessment 33. What documentation to include for abuse pts 34. Male nurse swings on female nurse for pushing him out of the way of a gurney. What is the kind of abuse? 35. Anorexic pt asking to work as a cook what is the nurse best response? 36. Client overdose on acetaminophen (Tylenol). What should the nurse monitor next? 37. Client is increasing getting aggressive 38. Angry pt because of coworkers, then a car accident, what is the nurse best response? 39. The nurse is teaching a pt about disulfiram (Antabuse) On admission to a residential care facility, an elderly female client tells the nurse that she enjoys cooking, quilting, and watching television. Twenty-fours after admission, the nurse notes that the client is withdrawn and isolated. It is best for the nurse to encourage this client to become involved in which activity? A male adolescent is admitted with bipolar disorder after being released from jail for assault with a deadly weapon. When the nurse asks the teen to identify his reason for the assault, he replies, "Because he made me mad!" Which goal is best for the nurse to include in the client's plan of care? The client will A 35-year-old male client who has been hospitalized for two weeks for chronic paranoia continues to state that someone is trying to steal his clothing. Which action should the nurse implement? A nurse working on a mental health unit receives a community call from a person who is tearful and states, "I just feel so nervous all of the time. I don't know what to do about my problems. I haven't been able to sleep at night and have hardly eaten for the past 3 or 4 days." The nurse should initiate a referral based on which assessment? A child is brought to the emergency room with a broken arm. Because of other injuries, the nurse suspects the child may be a victim of abuse. When the nurse tries to give the child an injection, the child's mother becomes very loud and shouts, "I won't leave my son! Don't you touch him! You'll hurt my child!" What is the best interpretation of the mother's statements? The mother is An anxious client expressing a fear of people and open places is admitted to the psychiatric unit. What is the most effective way for the nurse to assist this client?. The nurse suspects child abuse when assessing a 3-year-old boy and noticing several small, round burns on his legs and trunk that might be the result of cigarette burns. Which parental behavior provides the greatest validation for such suspicions? The nurse is planning care for a 32-year-old male client diagnosed with HIV infection who has a history of chronic depression. Recently, the client's viral load has begun to increase rather than decrease despite his adherence to the HIV drug regimen. What should the nurse do first while taking the client's history upon admission to the hospital? A 35-year-old male client on the psychiatric ward of a general hospital believes that someone is trying to poison him. The nurse understands that a client's delusions are most likely related to his The nurse plans to help an 18-year-old female mentally retarded client ambulate the first postoperative day after an appendectomy. When the nurse tells the client it is time to get out of bed, the client becomes angry and tells the nurse, "Get out of here! I'll get up when I'm ready!" Which response is best for the nurse to make? A client is admitted with a diagnosis of depression. The nurse knows that which characteristic is most indicative of depression?. A 65-year-old female client complains to the nurse that recently she has been hearing voices. What question should the nurse ask this client first? woman who is bipolar is wearing low cut blouse, and skirt with no underwear, what does nurse do? Older man who recently got divorced and is 2 years sober, and an alcoholic loves God. He loves kids also. What should nurse ask at his initial interaction? Woman is diagnosed with breast cancer and she becomes dependent and asks family members if they can do ADL's that she is fully capable of doing. What is the reason for this behavior? Patient having to get treated for benzodiazepam and methadone overdose. What do you use? Patient watching TV starts talking loud to himself. The nurse comes in and can't distract him so turns down the TV. What should the nurse do then? In group therapy the charge nurse notices a client increasing to severe levels of anxiety. What should the nurse do? A chronic depressed older man refuses to leave his room. His family moved away to a further location so they're not able to visit him as much. What approach should the nurse take with this man? Patient who is really depressed and won't talk or communicate, later is energetic and talkative. What should the nurse do? Patient who had generalized anxiety disorder on Xanax long-term. What is the outcome? Mother has a 9 month old baby with mental issues and growth issues. The mother comes in and says she's depressed because she’ll never have a normal baby. What should the nurse say? Lithium level 1.5. What do you tell the client who had a recent suicide attempt after seeing him become very anxious after hearing his Lithium levels? Woman comes into ED having been raped by her date. What should the nurse document? Which patient would require CAGE assessment? A nurse is changing a dressing on a bipolar patient's stomach from self-inflicting knife wound. What is the nurse's best approach? Woman is at a meeting with you, what is important for the nurse to document after hearing her issues in the relationship patient in corner with paranoid symptoms, staring and watching you. They refused to communicate with you. What do you do? patient states "I can't get my thoughts together I should really sell my car. It’s not in here. Let's buy a car. What is the patient experiencing? A depressed adolescent becomes sarcastic and irritates when you start to ask him questions. What does the nurse do? A patient who has been on an antidepressant for 2 weeks. What should you watch for? A patient won't take oral meds that is going through alcohol withdrawal. The nurse starts giving saline lock per alcohol protocol and thiamine. What do you tell them that it will help with recovery? A male patient got divorced a year ago, lost his job, and recently suffered from a break up. What is his reason for his recent depression? A patient is being admitted for drug overdose. She says the reason she is using drugs is because of a recent breakup of an intimate relationship? what does the nurse do first a bipolar patient has stopped taking an antipsychotic. What other medication should the nurse expect to be D/C what should you recommend to a patient saying she can't get any sleep recently after receiving news she has breast cancer. What medication should you recommend? A patient has possessions she doesn't trust anyone to hold because she thinks they will steal them. How does the nurse establish trust? Part Three 1. A male adult comes to the mental health clinic and walks back and forth in front of the office door, but does not enter the office. He then walks around a chair that is in the hallway several times before sitting down in the chair. What action should the nurse take first observe 2. A female client engages in repeated checks of door and window locks. Behavior that prevents her from arriving on time and interferes with her ability to function e²ectively. What action should the nurse take 3. A male client with schizophrenia is admitted to the mental health unit after abruptly stopping his prescription for ziprasidone (Geodon) one month ago. Which question is most important for the nurse to ask the client 4. A female client with a history of drinking who was admitted 8 hours ago after receiving treatment for minor abrasions occurred from a fall at home. 5. The nurse determines the client's blood alcohol level (BAL) was not analyzed on administration action should the nurse take 6. A female client on a psychiatric unit is sweating profusely while she vigorously does push-ups and then runs the length of the corridor several times before crashing into the furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbances, the client shouts," I am the boss here. I do what I want." Which nursing problem best supports these observations 7. What is the most important goal for a client diagnosed with major depression who has been receiving an antidepressant medication for two weeks 8. Alcohol-Pancreatitis health assessment of history of alcohol dependency WHAT ELSE WOULD BE A CONCERN 9. Anorexia Nervosa-syncope Syncope is a clinical feature 10. Admission A female client with a history of drinking who was admitted 8 hours ago after receiving treatment for minor abrasions occurred from a fall at home. The nurse determines the client's blood alcohol level (BAL) was not analyzed on administration action should the nurse take Blood alcohol level- 11. IPV- difficulty leaving victim of intimate partner violence what 3 things should you do 12. Anger Management Give the client 13. Antisocial- interrupting 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? 14. borderline personality disorder self-inflicted lacerations on abdomen perform the dressing change in a non-judgemental manner *ask to summarize-others need time also Borderline-interaction 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? C. Do you frequently have temper tantrums? Self-critical demanding, whiney, manipulative, argumentative and can be verbally abusive suicidal gestures. borderline personality disorder self-inflicted lacerations on abdomen perform the dressing change in a non -judge mental manner. 15. Conversion disorder patient complains of blindness 16. Countertransference occurs when a mental health care professional Part five 17. After returning to work after a weekend off the nurse gets report that a depressed client has been in bed all weekend. What should the nurse to first? 18. A client with dementia uses the defense mechanism of confabulation. What is the reasoning? 19. A husband states to the nurse that his wife is not sleeping, buying impulsively, taking last minute trips, and has lost 22 pounds one month. What is an appropriate nursing dx? HESI MENTAL HEALTH V3 2017 55 QUESTIONS 20. A nurse is explaining a fire drill routine to a group of clients. A client becomes disruptive and continually interrupts the group. What is the nurse's best response? 21. When performing a MSE on a client which assessment intervention would best assist the nurse? 22. A client comes in after being in a car accident and is experiencing alcohol withdrawal, magnesium level of 1.1, cardiac dysthrythmias. What would you give first? 23. A woman is just told of her husband's dx of terminal cancer. What would the nurse offer for the spouse (wife)? 24. A nurse is to remove staples from an abdominal incision, the client is very anxious. What is the most important intervention? 25. A man who was stranded on the roof of his house for two days after a natural disaster, months later ... 26. A man dx with bipolar disorder states, "I don't understand, I believe in God and have not done anything to deserve this". What is the nurse's best response? 27. A client becomes upset when the nurse he requests is not assigned to him, what is the nurse's best response? 28. A client needs to wash her hands for two hours before able to go on with her morning. She doesn't want to sit on the chairs in the dayroom for fear of getting dirty. What is this mechanism? 29. A client in group is talking about her prostitution, the nurse asks her if she was abused by her parents. She states "my mother ran my father out when I was young". What defense mechanism was used? 30. A woman calls the crisis hotline and says she has a loaded gun and is going to kill herself. To maintain patient confidentiality what would the nurse do? 31. A client with anger management issues uses belt making and bangs the leather heavily. What defense mechanisms is being used? 32. A bipolar client comes into the clinic and tells the nurse that the next time she sees her sister I'm going to kill her. What should the nurse do? 33. What would be the nurse's highest priority for a newly admitted depressed client upon admission? 34. Who is most prone to being abused (elder abuse)? 35. A client in the dayroom had tipped over a table and is escalating and has picked up a chair which he is threatening to throw at another client. What should the nurse do first? 36. A woman who is psychotic is carrying all of her belongings around with her because she is afraid that someone will steal it. What is the best way to establish trust? . 37. In adolescent group discussing a handout on anger management, a client is becoming increasingly interruptive and talking about his home and pets. What is the nurse's most appropriate response? 38. What is the most important intervention for a client with bulimia? 39. A client comes into the ED with DTs. What should the nurse do first? 40. What are the side effects of Resperdal? 41. A client who is refusing to take his medication is wandering on the unit and going in and out of resident's rooms. What is the priority? 42. A nurse observes a client in the dayroom talking to himself. What should the nurse do first? 43. A client comes to the nurses' station and told the nurse that her roommate had cut her wrists in the bathroom. After assessing and dressing the wounds, what should the nurse do next? 44. A man comes into the ER after being in a car accident with an alcohol level greater than 2, what should the nurse prepare to administer? 45. What would be proper teaching for a client who is to start taking Antabuse? 46. Alzheimer's patient-nurse goes to do dressing change and the client refuses. What should the nurse do? 47. A client is confused in an acute care hospital setting. What would support the dx of delirium instead of dementia? 48. An elderly woman is brought to the ER with multiple stages of healing bruises. What should the nurse do? 49. A business man is stressed about his finances, has anxiety and sleeplessness. 50. A mother comes into the clinic with her son who is being accused of a crime. She is worried her son will go to jail. What should the nurse say to the mother? 51. What is a common side effect of cocaine use. 52. A client on LSD comes into the ER. How do you approach the client? 53. A client taking Meth and Benzo's, what would the nurse prepare to do for overdose? 54. An alcoholic father tells his wife and children to stay away from him. What is the most important nursing dx? 55. onWhat should you advise a patient a MAOI not to eat? 56. The parents of a teenager who has overdosed what is the first question to ask? 57. A client becomes agitated when the nurse is talking to his wife. He has not eaten in 3 days. What should the nurse do? 58. When opening a mental health clinic... 59. A client with a hx of depression and abusing alcohol with their depression getting worse. What is the most important nursing dx? 60. A woman is being abused by her husband, the abuse is escalating. What would the nurse ask first? 61. A patient has stopped taking Depakote six months ago, what would the nurse assess? 62. A nurse visits a community half way house with one bathroom. The nurse notices urine all over the walls of the bathroom. The toilet is clogged with feces and paper towels. 63. A client with Alzheimer's keeps asking for his mother. What is the nurses appropriate response? 64. A client is told to come in by friends, clients complaints include losing his job, just got a divorce, single dad with two kids, what would be the best question for nurse to ask? 65. What are the side effects of Lithium? 66. A client with an anxiety disorder is demonstrating signs of panic. Which intervention would be the most appropriate for the nurse to implement . 67. A client tells the nurse that he is an accomplished writer and that directors of television shows contact him for suggestions on actors and locations. The nurse realizes this client is experiencing the delusion of 68. A client tells the nurse that his father died after the client thought abut it for a few days. The nurse suspects the client is delusional and is demonstrating: 69. The nurse overhears a client diagnosed with terminal cancer tell a family member that he will be discharged soon, will return to work, and plans to attend a company event scheduled in a year. The nurse realizes this client is demonstrating the defense mechanism of 70. A female client diagnosed with depression tells the nurse that her husband wants her to “fix herself up” and put on nice clothes. The client continues by saying that she believes her husband is interested in another woman. What should the nurse respond to the client? 71. A client diagnosed with schizophrenia has been refusing prescribed oral medication for several days. The client has broken chair and is coming after another client with the broken chair leg, threatening to do physical harm. What should the nurse do first? 72. The nurse has identified the diagnosis imbalance Nutrition: More than body requirements for a client diagnosed with bulimia. Which intervention would be appropriate for this diagnosis? 73. A client tells the nurse that he has a fear of flying on an airplane but needs to attend a work-related meeting in another part of the country and will have to fly to get there. What can the nurse do to assist this client? 74. During an assessment, a client from the Hispanic culture refuses to maintain eye contact with the nurse. After the nurse overhears the client say “evil eye” to a family member, the nurse realizes the client is demonstrating characteristics of which cultural-specific syndrome? 1. A male client with schizophrenia is admitted to the mental health unit after abruptly stopping his prescription for ziprasidone (Geodon) one month ago. Which question is most important for the nurse to ask the client 2. A female client with a history of drinking who was admitted 8 hours ago after receiving treatment for minor abrasions occurred from a fall at home. The nurse determines the client's blood alcohol level (BAL) was not analyzed on administration action should the nurse take 3. A male client is admitted to the psychiatric inpatient unit with a bandaged flesh wound after attempting to shoot himself. he is recently divorced one year ago, lost his job four months ago, and suffered a break up of his current relationship last week. What is the most likely source of this client's current feelings of depression 4. What is the most important goal for a client diagnosed with major depression who has been receiving an antidepressant medication for two weeks 5. A male adult comes to the mental health clinic and walks back and forth in front of the office door, but does not enter the office. He then walks around a chair that is in the hallway several times before sitting down in the chair. What action should the nurse take first 6. A male client in the mental health unit is guarded and vaguely answers the nurse's questions. He isolates to his room and sometimes opens the door to peek into the hall. Which problem can the nurse anticipate 7. A male client who is seen in the mental health clinic monthly reports feeling very stressed and nervous and further describes becoming angry increasingly more often during the last month. What action should the nurse take first 8. A 26-year-old female client has been particularly restless and the nurse finds her trying to leave the psychiatric unit. She tells 9. her the nurse," please let me leave because the secret police are after me." Which response is best for the nurse 10. The nurse is preparing medications for a client with bipolar disorder and notices that the antipsychotic medication was discontinued several days ago. Which medication should also be discontinued 11. A young woman is preparing to be discharged from the psychiatric unit. Which nursing intervention is most important for the nurse to include in this phase of the nurse client relationship 12. A female high school teacher who was a child of alcoholic parents seeks counseling at the community health clinic because of depression over a student who was killed by a drunk driver. After several weeks of counseling, which behavior is the best indicator that the client is coping well with the anxiety related to the student's death 13. A male client arrives at the mental health clinic and asks the nurse for more lithium and the antidepressant (Elavil) that he uses to help him sleep. After reviewing his assessment findings with the healthcare provider, a serum creatinine is obtained. What information supports the reason for this laboratory test 14. The nurse is teaching a client about the initiation of a prescribed abstinence therapy using disulfiram (Antabuse). What information should the client acknowledge understanding? 15. When preparing to administer a domestic violence screening tool to a female client, which statement should the nurse provide 16. A client with schizophrenia who is taking Haldol begins exhibiting tremors of the extremities. Which intervention should the nurse implement 17. A male client with bipolar disorder tells the nurse that he needs to "make some deals so that he can improve his retirement savings." Based on this information, which client outcome should the nurse include in the plan of care 18. one on one session and nurse begins to get angry at patient 19. patient with schizophrenia, drug and alcohol abuse in hospital for hepatitis, contact healthcare provider before giving 20. teenaged girl self-induced vomiting 21. antidepressant side effects 22. no TV in room tell patient 23. A woman who started chemotherapy three days ago for cancer of the breast calls the clinic reporting that she is so upset she cannot sleep. The client has several PRN medications available. Which drug should the nurse instruct her to take? 24. A male adult is admitted because of an acetaminophen (Tylenol) overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client's discharge plan? 25. patient being discharged 26. depressed mother and daughter speaks in group 27. A client who has agoraphobia (a fear of crowds) is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care? 28. When a male client is asked about his reason for coming to the mental health clinic he replies, "It all started because I work in a hostile work environment. My boss would not let me go to a religious service, so I went to human resources, and they didn't want to do anything. It has been a really difficult time for me." Which response should the nurse provide? 29. ECT therapy non responsive 30. adolescent teen interrupts group about pets at home 31. client in bed all weekend, depression 32. postpartum depression Sign & Symptoms (3) 33. ECT 34. stealing clothes 35. health assessment of history of alcohol dependency WHAT ELSE WOULD BE A CONCERN 36. knee surgery post op and diaphoretic and visual hallucinations 37. aspiration due to caustic material related to suicide attempt 38. A 38-yea- old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her food to eat and tells the nurse, "I know you are trying to poison me with that food." Which response would be most appropriate for the nurse to make? 39. During a one-to-one session, the nurse begins to become angry with the client. Which action should the nurse take? 40. A MHW mental health worker is caring for a client with escalating aggression behavior, what action by the MHW warrants immediate intervention by the nurse •MENTAL HEALTH 25 QUESTIONS RN 2017 1. A female client with a history of drinking who was admitted 8 hours ago after receiving treatment for minor abrasions occurred from a fall at home. The nurse determines the client's blood alcohol level (BAL) was not analyzed on administration action should the nurse take? 2. A male client is admitted to the psychiatric inpatient unit with a bandaged flesh wound after attempting to shoot himself. he is recently divorced one year ago, lost his job four months ago, and suffered a break up of his current relationship last week. What is the most likely source of this client's current feelings of depression? 3. What is the most important goal for a client diagnosed with major depression who has been receiving an antidepressant medication for two weeks? 4. A male adult comes to the mental health clinic and walks back and forth in front of the office door, but does not enter the office. He then walks around a chair that is in the hallway several times before sitting down in the chair. What action should the nurse take first 5. A male client in the mental health unit is guarded and vaguely answers the nurse's questions. He isolates to his room and sometimes opens the door to peek into the hall. Which problem can the nurse anticipate? 6. A male client who is seen in the mental health clinic monthly reports feeling very stressed and nervous and further describes becoming angry increasingly more often during the last month. What action should the nurse take first? 7. A young woman is preparing to be discharged from the psychiatric unit. Which nursing intervention is most important for the nurse to include in this phase of the nurse client relationship? ( 8. A female high school teacher who was a child of alcoholic parents seeks counseling at the community health clinic because of depression over a student who was killed by a drunk driver. After several weeks of counseling, which behavior is the best indicator that the client is coping well with the anxiety related to the student's death? 9. A male client arrives at the mental health clinic and asks the nurse for more lithium and the antidepressant (Elavil) that he uses to help him sleep. After reviewing his assessment findings with the healthcare provider, a serum creatinine is obtained. What information supports the reason for this laboratory test? When preparing to administer a domestic violence screening tool to a female client, which statement should the nurse provide? 10. A client with schizophrenia who is taking Haldol begins exhibiting tremors of the extremities. Which intervention should the nurse implement? 11. A woman who started chemotherapy three days ago for cancer of the breast calls the clinic reporting that she is so upset she cannot sleep. The client has several PRN medications available. Which drug should the nurse instruct her to take? 12. When a male client is asked about his reason for coming to the mental health clinic he replies, "It all started because I work in a hostile work environment. My boss would not let me go to a religious service, so I went to human resources, and they didn't want to do anything. It has been a really difficult time for me." Which response should the nurse provide? 13. A client with a history of chronic alcohol abuse... what other medical condition to suspect 14. A client with paranoia is admitted to the mental health unit and immediately goes to the corner of the room and sits quietly without communicating. In approaching the client, what intervention should the nurse implement first? 15. A client comes out dressed in short skirt, low top, bright red lipstick.. what should the nurse do 16. A client comes in and is 5'5, 75lbs.. what should the nurse do 17. A child states "My dad used to drink a beer a day, now he drinks at least a six-pack a day." What can the nurse determine from this statement? 18. 2 days after admission from alcohol withdrawal what should the nurse do? 19. Something about a male client threatening a teacher or becomes upset with teacher 20. Methods of clearly communicating (If you see this answer.. pick it!) 21. History of alcoholism admitted for detoxification; 6mg of Ativan what additional 22. PTSD admitted to psychiatric unit, which intervention is most important for plan of care 23. Chronically depressed older male client of a long term care facility becomes more reclusive and today refuses to leave room 24. Male client on atypical antipsychotic drug olanzapine(Zyprexa) 25. Client sitting in corner of day room during admission assessment, what nursing action 26. How do you take Antabuse 1. The nurse is using the CAGE questionnaires as a screening tool for a client who is seeking help because his wife said he had a drinking problem. What information should the nurse explore indepth with the client based on this screening tool? A client who is admitted with a closed head injury after a gall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the nurse identify as the priority? The nurse leading a group session of adolescent clients give the members handout about anger management. One of the male clients is fidgety, interrupts peers when they try to talk, and talks about his pets at home. What nursing action is best for the nurse to take? The nurse is preparing medications for a client with bipolar disorder and notices that the antipsychotic medication was discontinued several day ago. Which medication should also be discontinued? A middle-aged adult with major depressive disorder suffer from psychomotor redardation, hypersomnia, and amotivation. Which intervention is like to be most effective in returning this client to a normal level of functioning? A male client with a long history of alcohol dependency arrives in the Emergency department describing the feeling of bugs crawling on his body. His blood pressure is 170/102, pulse rate is 110 beats/ min, and his blood alcohol level is 0 mg/dl. Which prescription should the nurse administer? The nurse is teaching a client about the initiation of a prescribed abstinence therapy using disulfiram (Antabuse). What information should the client acknowledge understanding? A female client reports feeling hopeless and is unable to stop crying. She explains that she is worried about losing her job. Since the client’s husband recently lost his job she feels her employment is essential to the family’s survival. To evaluate the effectiveness of cognitive-behavioral techniques, which client outcomes should the nurse include in the plan of care? A female client engages in repeated checks of door and window locks, behavior that presents her from arriving on time and interferes with her ability to function effectively. What action should the nurse take? A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. That intervention is best for the nurse to implement? A young adult male is hospitalized due to depression and an attempted suicide attempt. The client reports that he lost his job and was angry with his employer for firing him when he took an overdose of pain medications. Which behavior best indicates to the nurse that his condition is improving? The nurse is completing the admission assessment of an underweight adolescent who is admitted to a psychiatric unit with a diagnosis of depression. Which finding requires notification to the healthcare providers Following involvement in a motor vehicles collision, a middle-aged adult client is admitted to the hospital with multiple facial fractures, The client’s bold alcohol level is high on admission. Which PRN prescription should be administered if the client begin to exhibits signs and symptoms of delirium tremors (DT)? A female client, who is wearing dirty clothes and has afoul body odor, comes to the clinic reporting feeling scared because she is being stalked. What action is most important for the nurse to take? A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit’s day room. What action should the nurse implement first? A teenager who has lost 20 pounds in the last three months is admitted to the hospital with hypotension and tachycardia. The client reports irregular menses and hair loss. Which intervention is most important for the nurse to include in the clients plans of care? The nurse is developing unit policies that will include nursing guidelines for maintaining a therapeutic milieu. Which interventions should be included when providing a therapeutic milieu in an inpatient setting? After receiving treatment for anorexia, a student asks the school nurse for permission to work in the school cafeteria as part of the school’s work study program. What action should the nurse take? A middle-aged female client with no previous psychiatric history is seen in the mental health clinic because her family describes her as having paranoid thoughts. On assessment, she tells the nurse “I want to find out why these people are stalking me” which response should the nurse provide? A male veteran who recently returned from a war zone has post traumatic stress disorder (PTSD) and is admitted to the psychiatric ward because of admitted suicidal ideation. On admission, the client’s family informed the HCP that therapy sessions did not seem to be helping. Select only one intervention that as the highest priority? A male adolescent was admitted to the unit two days ago for depression. When the mental health nurse tries to interview the client to establish rapport, he becomes very irritated and sarcastic. Which action is best for the nurse to take? A female high school teacher who was a child alcoholic parents seeks counseling at the community health clinic because of depression over a student who was killed by a drunk driver. After several weeks of counseling, which client behavior is the best indicator that the client is coping well with anxiety related to the student’s death? While interviewing a client, the nurse takes notes to assist with accurate documentation later. Which statement is most accurate regarding note-taking during an interview? An adolescent make receives a prescription for an antidepressant drug because he is exhibiting a depressed affect. While the client is taking the antidepressant, which comparison of the client’s behavior before and after taking the drug is most important for the nurse to obtain? A nurse is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? While setting in the dayroom of the mental health unit, a male adolescent avoids eye contact, looks at the floor, and talks softly when interacting verbally with the nurse. The two trade places, and the nurse demonstrate the client’s behavior. What is the main goal of this therapeutic techniques? [Show More]

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