Module 4 Exam: HESI Module 4 Exam: HESI Module 4 Exam: HESI

Module 4 Exam: HESI Module 4 Exam: HESI Module 4 Exam: HESI 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 1/116 Questi ...

Module 4 Exam: HESI Module 4 Exam: HESI Module 4 Exam: HESI 7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 1/116 Question 1 1 / 1 pts A client with schizophrenia says, “I’m away for the day ... but don’t think we should play … or do we have feet of clay?” Which alteration in the client’s speech does the nurse document? Neologism Word salad Correct! Correct! Clang association Associative looseness Rationale: Clang association is the meaningless rhyming of words in which the rhyming is more important than the context of the words. A neologism is a made-up word that has meaning only to the client. Word salad is the term for a mixture of meaningless phrases, either to the client or to the listener. Associative looseness is a term used to describe schizophrenic speech in which connections and threads are interrupted or missing. Test-Taking Strategy: Knowledge of the speech patterns exhibited by the client with schizophrenia is needed to answer this question. Focus on the data in the question and note the meaningless rhyming of words. Review these speech patterns with schizophrenia if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Question 2 1 / 1 pts7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 2/116 A client with schizophrenia and his parents are meeting with the nurse. One of the young man’s parents says to the nurse, “We were stunned when we learned that our son had schizophrenia. He was no different than from his older brother when they were growing up. Now he’s had another relapse, and we can’t understand why he stopped his medication.” Which response by the nurse is appropriate? Telling the parents, “Medication noncompliance is the most frequent reason that people with this diagnosis relapse.” Telling the parents, “Well, it’s his decision to take his medicine, but it’s yours to have him live with you if he stops the medication.” Asking the client, “How can we help you to take your medicine or to tell us when you’re having problems so that your medication can be adjusted?” Correct! Correct! Saying to the parents, “Your concerns are appropriate, but I wonder whether your son was having trouble telling someone that he had concerns about his medication.”7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 3/116 Rationale: The therapeutic response is the one in which the nurse models speaking directly to the client. This facilitates further assessment of the situation and helps elicit the causes of and motivations for the client’s behavior for both the nurse and the family. In the correct option, the nurse also seeks clarification of the degree of openness and mutuality felt by the client and his family toward each other. The nurse provides information to the family when stating that noncompliance is the most frequent reason for relapse in people with this diagnosis. However, the statement is nontherapeutic at this time because it does not facilitate the expression of feelings. The nurse uses a superego style of communication when stating, “Well, it’s his decision to take his medicine, but it’s yours to have him live with you if he stops the medication.” The content of this statement may be true, but it is nontherapeutic in that it carries a threatening message and may prevent the family from trusting the nurse. By stating “Your concerns are appropriate, but I wonder whether your son was having trouble telling someone that he had concerns about his medication,” the nurse gives approval and prematurely analyzes the client’s motivation without sufficient assessment. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques and remember to focus on the client’s feelings. Also note that the correct option is the only option in which the nurse directly addresses the client. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Question 3 1 / 1 pts An acutely ill client with schizophrenia says to the nurse, “He keeps saying that he likes you, and I keep telling him you’re married, but he won’t listen, and I think he’s going to get fresh with you.” Once the nurse has determined that the client is7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 4/116 hallucinating, which response to the client would be most appropriate statement? “Try not to listen to the voices right now so that I can talk with you.” Correct! Correct! “I think that you can help him stop his behavior if you concentrate.” “Tell him I said to mind his p’s and q’s or I’ll call the police on him.” “I think that you’re trying to share your own feelings toward me, but you’re shy.” Rationale: The appropriate statement by the nurse is the one that does not acknowledge the client’s hallucinations. By responding “I think that you can help him stop his behavior if you concentrate” or “Tell him I said to mind his p’s and q’s or I’ll call the police on him,” the nurse acknowledges the hallucinations. The nurse attempts to interpret the client’s thinking with a statement such as “I think that you’re trying to share your own feelings toward me, but you’re shy.” Test-Taking Strategy: Use your knowledge of therapeutic communication techniques and remember that the nurse should not acknowledge the client’s hallucinations. Also note that the correct option is the only one that encourages realistic verbalization from the client. Review therapeutic communication techniques with a client who is hallucinating if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 5/116 Question 4 0 / 1 pts A client says to the nurse, “It’s over for me—the whole thing is over.” Which response by the nurse would be therapeutic? Y You Answered ou Answered “What do you mean, ‘The whole thing is over’?” “Over? Well, that sounds pretty drastic to me. Let’s discuss this in the strictest confidence.” “Can you tell me more about why it’s over for you? I’ll keep your thoughts strictly confidential.” “Let’s talk more about your feeling that the whole thing is over for you. This is important, and I may need to share your feelings with other staff members.” Correct Answer Correct Answer7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 6/116 Rationale: The therapeutic response seeks clarification, employs paraphrasing, and informs the client that the nurse needs to share any information that requires crisis intervention with other staff members. Asking “What do you mean, ‘The whole thing is over’?” employs paraphrasing, but the message is blunt and closed-ended. In stating “Over? Well, that sounds pretty drastic to me. Let’s discuss this in the strictest confidence,” the nurse uses hysterical exaggeration (at an inappropriate time) and gives incorrect information regarding confidentiality. In stating “Can you tell me more about why it’s over for you? I’ll keep your thoughts strictly confidential,” the nurse uses the therapeutic technique of seeking clarification but does not clarify with the client that the information might need to be shared. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that indicate that shared information will be maintained as confidential. To select from the remaining options, focus on the statement that addresses the client’s feelings. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Communication and Documentation Content Area: Mental Health Question 5 1 / 1 pts A nurse performing a lethality assessment asks the client whether he is thinking of suicide. Which statement by the client would be of most concern to the nurse? Correct! Correct! “No, I wasn’t, but I am now, thanks to you.” “I hadn’t thought of that, but I can see that you are.” “Of course not, but there are days when I think that I should be.”7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 7/116 “What is suicide going to do for me except get me excommunicated from the church?” Rationale: The client’s response that he is now thinking about suicide is of the greatest concern to the nurse. In making the statement “I hadn’t thought of that, but I can see that you are” the client projects his own thoughts of suicide onto the nurse. In stating “Of course not, but there are days when I think that I should be,” the client is being sarcastic but is not specifically talking about suicide. In stating “What is suicide going to do for me except get me excommunicated from the church?” the client indicates that suicide is not an option because of his religious beliefs. Test-Taking Strategy: Use the process of elimination and note the strategic words “of most concern to the nurse.” Note the words “but I am now” in the correct option. This is the only option that identifies definite suicidal thoughts. Review lethality assessment in the suicidal client if you had difficulty with this question. Cognitive Ability: Analyzing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Assessment Content Area: Mental Health Question 6 1 / 1 pts A client who has expressed suicidal ideation in the past says to the nurse, while shuffling several documents in an effort to organize them, “Well, I’m feeling so much better now since I got organized. My lawyer wrote my will and durable power of attorney.” Which response by the nurse is appropriate? “Good grief! You don’t look organized to me.”7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 8/116 “Okay, what are you up to today? Your behavior is not appropriate.” “You talk about getting organized. Are you thinking of killing yourself?” Correct! Correct! “If you keep behaving like this, you know that I’ll have to tell the doctor, and we’ll have to seclude you.” Rationale: The client is exhibiting behaviors that indicate plans for suicide. Talking of suddenly “feeling so much better” and putting affairs in order are key verbal and behavioral clues that the client is planning to commit suicide. In exclaiming “Good grief! You don’t look organized to me,” the nurse nontherapeutically uses hysterical exaggeration, which minimizes the client’s feelings. In asking “Okay, what are you up to today? Your behavior is not appropriate,” the nurse uses teasing to determine the client’s behaviors, which minimizes them. Additionally, the nurse is employing a nontherapeutic technique of judging. In stating “If you keep behaving like this, you know that I’ll have to tell the doctor and we’ll have to seclude you,” the nurse uses a threat. Test-Taking Strategy: Use the process of elimination. Focus on the information in the question and note the relationship between the words “expressed suicidal ideation” in the question and “thinking of killing yourself” in the correct option. Review the clues that indicate the potential for suicide if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Communication and Documentation Content Area: Mental Health Question 7 1 / 1 pts7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 9/116 An adolescent client says, “I’m just a burden to my folks. They wish I’d never been born. My dad told me he had to marry Mom because she got pregnant.” Which response by the nurse would be therapeutic? “You’re feeling that your folks didn’t want you, but they chose to marry and have you.” Correct! Correct! “You feel that you were a burden and not wanted? Let’s talk with your parents to see whether you’re right.” “Let’s speak with your parents about what you’ve just told me. Let’s ask whether you were truly unwanted.” “Sounds like your father was very inappropriate, but I’m certain that he didn’t mean that you were a burden to him.”7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 10/116 Rationale: In the correct option, the nurse uses reflection to explore the client’s lethality risk and then uses reframing to determine whether the client is able to view what happened in a different way. In suggesting “You feel that you were a burden and not wanted? Let’s talk with your parents to see whether you’re right,” the nurse uses paraphrasing but is then nontherapeutic in trying to persuade the client to talk to the parents. In suggesting “Let’s speak with your parents about what you’ve just told me. Let’s ask whether you were truly unwanted,” the nurse uses a parental approach, which may be threatening to the client, who seems to have been unable to talk with the parents before now. In stating “Sounds like your father was very inappropriate, but I’m certain that he didn’t mean that you were a burden to him,” the nurse offers an opinion about the client’s father and then provides false reassurance. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that address discussing the client’s feelings with the parents. In selecting from the remaining options, remember to focus on the client’s feelings. Select the option that exemplifies therapeutic communication technique. This will direct you to the correct option. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Question 8 1 / 1 pts A client says to the nurse, “I’ve ruined my life. I left college with only a few credits to go. I keep telling myself that I’m going to make it as a writer, but I’ll be a loser and a nothing for the rest of my life.” Which response by the nurse is therapeutic? “What are you saying? Sounds like you need to pull yourself together and go back to school.”7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 11/116 “Having faith in yourself is one thing, but looking at your alternatives realistically is another.” “You seem to be saying that your choices are final and that you’ve lost any other opportunities.” Correct! Correct! “Sounds like you feel that things should come easy for you, unlike the rest of us, who work for what we get.” Rationale: The client in this question is engaging in catastrophizing rather than reframing and viewing other alternatives. The task for the nurse is to assess the client’s situation and to help the client feel empowered to take another course of action and find the perseverance and confidence to do so. The therapeutic response here is the one that is nonjudgmental. In responding “What are you saying? Sounds like you need to pull yourself together and go back to school,” or “Sounds like you feel that things should come easy for you, unlike the rest of us, who work for what we get,” the nurse communicates with the client as a parent, using a judging style. In stating “Having faith in yourself is one thing, but looking at your options realistically is another,” the nurse communicates prematurely and gives advice. Test-Taking Strategy: Use the process of elimination and your knowledge of therapeutic communication techniques. Eliminate the comparable or alike options that demonstrate the nurse using a judging style to deal with the client. To select from the remaining options, eliminate the option that is nontherapeutic in that the nurse gives advice. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 12/116 Question 9 1 / 1 pts A client who has twice attempted suicide says, “If people would just leave me alone and let me do what I want with my life, I could get on with what I want to do.” Which response should the nurse should give to the client? “Of course you can’t be left alone to get on with what you want to do.” “Okay, go ahead and do whatever you want to do. Human beings have free will.” “You’ve tried to end your life twice, yet you feel that everyone should let you do what you want to do?” Correct! Correct! “Sounds like you’re angry with people for caring enough about you to try to keep you from hurting yourself.”7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 13/116 Rationale: The therapeutic response is the one that offers reflection, which permits the client to observe the content of what she is saying. In stating “Of course, you can’t be left alone to get on with what you want to do,” the nurse makes a response that is social and belittles the client’s feelings. In stating “Okay, go ahead and do whatever you want to do. Human beings have free will,” the nurse makes a response that seems sarcastic and angry; it is also judgmental and biased. In stating “Sounds like you’re angry with people for caring enough about you to try to keep you from hurting yourself,” the nurse makes a premature judgment. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. The correct option is the only response that is therapeutic in that it uses reflection. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Communication and Documentation Content Area: Mental Health Question 10 1 / 1 pts A homeless client with an antisocial disorder is brought to the emergency department by the police after disturbing customers in a department store. The client says to the nurse, “I need to be hospitalized. It’s getting cold out, and I need a warm bed. If you don’t get me into a hospital, I’ll jump off a bridge.” Which nursing intervention would be therapeutic? Sending the client to the psychiatric hospital intake center immediately for evaluation Asking the police to pick the client up and arrest him for vagrancy, as they should have done immediately7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 14/116 Discharging the client with a follow-up appointment for the next day and guaranteeing him a hospital bed if he shows up Sending the client to a shelter that will provide temporary housing if he signs a contract agreeing not to attempt suicide Correct! Correct! Rationale: The client is clearly using suicide as a threat so that he will be hospitalized. As long as self-harm is not an issue, providing the client with shelter will meet his needs. Sending the client to the psychiatric hospital intake center immediately for evaluation is an intervention that should be used if the client refuses to sign a contract for “no suicide.” Guaranteeing the client a hospital bed if he shows up for a follow-up appointment is manipulation, which is a nontherapeutic intervention. The nurse would not order the police to arrest a client. Test-Taking Strategy: Use knowledge of the subject, selfharm issues, to assist you with the process of elimination. Eliminate the option that indicates arresting the client, because it is not the nurse’s role to determine who requires arrest by the police. Next eliminate the option that involves manipulation. From the remaining options, select the option that provides the client shelter and addresses the risk of self-harm. Review self-harm issues and the appropriate nursing interventions if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Mental Health Question 11 1 / 1 pts A client is admitted to the medical-surgical unit of a hospital, and suicide precautions are taken until the client can be admitted to the psychiatric unit. Which nursing intervention does the nurse implement?7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 15/116 Placing the client in a private room and locking the client’s closets and bathroom Placing the client in a private room and removing all knives and glass from the client’s meal tray Allowing the client to go out on pass as long as the client is accompanied by a responsible adult Placing the client in a semiprivate room, providing plastic utensils for eating, and keeping an arm’s distance from the client at all times Correct! Correct! Rationale: When a client is suicidal, someone must be at arm’s length at all times, observing the client, and the client must be in view at all times, even while toileting and showering. Plastic utensils are used for eating. A semiprivate room is better than isolation in a private room. Searching the client and the client’s room for harmful objects is done openly and randomly. Glass mirrors are removed and the bathroom is harm-proofed by replacing the metal shower curtain rod with a plastic rod that falls when 50 pounds of pressure is placed on it. Off-unit passes are not issued when a client is suicidal. Test-Taking Strategy: Use the process of elimination and focus on the subject, suicide precautions. Eliminate the options that are comparable or alike and involve the provision of a private room, because this environment further isolates the client. Next recall that a suicidal client would not be allowed off the nursing unit. Review suicide precautions if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Mental Health7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 16/116 Question 12 1 / 1 pts A client is admitted to the psychiatric inpatient unit and suicide precautions are instituted. Which intervention does the nurse implement? Restricting visitors Placing the client in a private room and locking the bathroom door Removing perfume, shampoo, and other toiletries from the client’s room Correct! Correct! Placing flowers brought to the client in a small glass vase and putting them in the client’s room Rationale: When suicide precautions are instituted, all of the client’s belongings that are potentially harmful are removed and placed in a locked area from which the nursing staff can retrieve them as the client needs to use them. Visitors are not restricted. However, any items that a visitor brings to the client must be checked by the nurse. Glass items are not placed in the suicidal client’s room. Test-Taking Strategy: Use the process of elimination and focus on the subject, suicide precautions. Eliminate the option that is a violation of client rights; the client is allowed to have visitors. Next eliminate the options that contain the words “private room” and “glass.” Review suicide precautions if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Mental Health7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 17/116 Question 13 1 / 1 pts A client who is undergoing psychiatric counseling calls a nurse on a hotline crying and states, “My priest assaulted me when I was an altar boy, and my dad just found out. He’s got a gun, and he’s driving over to the church rectory. I don’t know what to do.” Which response by the nurse is most appropriate initially? “How did your dad learn of your abuse by clergy?” “Call the police immediately and then call the priest to warn him that your dad has a gun.” “Call the priest immediately and tell him to lock the doors until the police arrive. I’ll call the police.” Correct! Correct! “You will want to come in to see our psychiatrist with your father, but for now, call the police and tell them what happened.”7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 18/116 Rationale: Usually the volunteers on hotlines are trained to keep the client on the line, but in this case, the duty to warn the priest of the danger he is facing is paramount. When violence erupts, the nurse must think and act quickly and with clarity. “How did your dad learn of your abuse by clergy?” is off focus and inappropriate to the situation. Telling the client “Call the police immediately and then call the priest to warn him that your dad has a gun” is incorrect because the priest should be warned first. In stating “You will want to come in to see our psychiatrist with your father, but for now, call the police and tell them what happened,” the nurse does not focus on the imminent violence described in the question. Test-Taking Strategy: Note the strategic words “initially.” Eliminate the comparable or alike options that direct the client to call the police first. To select from the remaining options, consider the seriousness of the situation. This will direct you to the correct option. The priest needs to be warned of the danger. Review nursing responsibilities in violent situations if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Mental Health Question 14 0 / 1 pts A nurse determines that a client whose son died in a car accident is at risk for self-harm. Which intervention is most appropriate initially? Correct Answer Correct Answer Making a “no suicide” contract with the client Telling the client that anger should be suppressed Providing a peaceful place for the client to meditate Y You Answered ou Answered Helping the client control expression of his feelings7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 19/116 Rationale: The nurse would first plan to implement a “no suicide” contract when a client is at risk for self-harm. The safety of the client is the priority. The nurse would encourage the client to express angry, hostile feelings, not suppress them. Providing a peaceful place for the client to meditate is incorrect because the nurse would not want the client to isolate himself. Rather, the nurse would promote social interaction for the client. The nurse would help the client express (not control expression of) feelings that are painful. Test-Taking Strategy: Use the process of elimination and note the strategic word “initially.” Note the relationship between the words “at risk for self-harm” in the question and “‘no suicide’ contract” in the correct option. Review initial interventions for the client at risk for suicide if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Mental Health Question 15 1 / 1 pts A client says to the nurse, “I’m worried about my husband. He’s talking about ending it all since his law practice dropped off and his son by his late first wife died of a drug overdose—but he’s too intelligent to hurt himself, isn’t he?” Which response by the nurse is appropriate? “Yes, he’s too intelligent to end it all.” “I’m not sure. I don’t know him that well.” “Most people who talk about ending it all are just looking for attention.”7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 20/116 “Your husband is displaying behaviors that indicate a risk for selfharm.” Correct! Correct! Rationale: Risk factors for suicide include male gender, professional status (physician, attorney, dentist, military personnel), loss to death, financial problems, and physical illness. Other risk indicators include a suicide plan, depressed mood, and prior attempts at suicide. In stating “Yes, he’s too intelligent to end it all,” the nurse provides false reassurance. In responding “I’m not sure. I don’t know him that well,” the nurse may be accurate, but the answer avoids the client’s concern. The statement “Most people who talk about ending it all are just looking for attention” is inaccurate. Any implication of suicide should be taken seriously. Test-Taking Strategy: Use the process of elimination and focus on the data in the question. Recalling the risk factors associated with suicide will direct you to the correct option. Review risk factors for self harm if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Question 16 1 / 1 pts A client says to the nurse, “I came in to see you because I’ve been off my medication for 4 years but I feel as though I may be getting depressed again. I’ve been despondent and thinking I should have ended it. That’s why I’m here to get help.” Which response by the nurse would be therapeutic? “Well, you really have had a good long drug-free time, but it sounds as if the doctor needs to reorder your medication at once.”7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 21/116 “If you’ve been able to be drug free all this time, you probably don’t need to restart the medicine. You probably just need some therapy to help you manage stress.” “Well, it’s been more than 4 years, so you’ve done really well. Sounds like you’re right about getting depressed again, though. Can you tell me what’s been happening with you lately?” Correct! Correct! “Well, it’s similar to when a client is battered; things have to boil over before the police can act, so you need to be suicidal to get admitted to a hospital or hurt yourself before the doctor can restart the medication.”7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 22/116 Rationale: The therapeutic response is the one in which the nurse validates the client’s drug-free time. In addition, in the correct option the nurse validates the client’s selfassessment and supports and offers positive reinforcement. Finally the nurse begins to assess the client completely and attempts to identify precipitants. By stating “Well, you really have had a good long drug-free time, but it sounds as if the doctor needs to reorder your medication at once,” the nurse is premature in determining that the medication needs to be restarted; a thorough assessment must be performed first. In stating “If you’ve been able to be drug free all this time, you probably don’t need to restart the medicine. You probably just need some therapy to help you manage stress,” the nurse jumps to giving advice and offering suggestions without performing a complete assessment. In stating “Well, it’s similar to when a client gets battered; things have to boil over before the police can act, so you need to be suicidal to get admitted to a hospital or hurt yourself before the doctor can restart the medication,” the nurse provides an incorrect statement and sarcastic information. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques and the steps of the nursing process, remembering that assessment is the first step. The only option that involves the process of assessment is the correct option. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Question 17 1 / 1 pts A client who delivered a baby 4 months ago says, “I keep thinking that this boy is some sort of demon. All he does is cry. It’s as if I can’t feed him enough or satisfy him in any way. My daughter never gave me this kind of trouble. I really can’t stand it.” Which statement by the nurse is most important?7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 23/116 Correct! Correct! “Have you been having any thoughts of hurting your baby?” “Do you think that something physically wrong is causing your baby to cry?” “Do you think that your baby cries so frequently because he’s not getting enough nourishment from breastfeeding?” “You say that he doesn’t seem to be satisfied. Do you feel that this is significantly different from when your daughter was a baby?” Rationale: The most important statement is the one in which the nurse assesses the client for her risk of harming the baby. This client may be experiencing postpartum depression, and the rumination over the baby could lead the mother to harm the baby. The statements in the incorrect options change the subject and close off expressions of concern by the client. Test-Taking Strategy: Use knowledge of the subject, potential for harm to others, to assist you with the process of elimination. Noting the words “I really can’t stand it” in the question will direct you to the correct option. Review assessment of the client at risk for harming others if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Communication and Documentation Content Area: Mental Health Question 18 1 / 1 pts A client who is an alcoholic has been admitted to the mental health unit and states to the nurse, “The judge made me come in here. My blood alcohol level was only 0.20% when the cop pulled7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 24/116 me over in my car.” Which statement by the nurse is most appropriate? “Did you ask the judge to clarify his decision to make you come here?” “This limit means that you had consumed enough alcohol to put you close to the legal intoxication level. You were lucky because you just missed that level.” “Well, the legal limit is much less than that, so you avoided a drunken driving charge by coming here. Seems to me that the judge treated you pretty leniently by allowing you to take refuge here. Don’t you agree?” “This level means that you consumed several drinks of alcohol and would be experiencing depressed motor function of the brain. You would have been staggering and clumsy, and your judgment would have been impaired, but you seem to feel that the judge was unreasonable for sending you here.” Correct! Correct!7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 25/116 Rationale: In most states (although the blood alcohol level, or BAL—designated as the indicator of intoxication—does vary), the legal alcohol limit is 0.08%. The most appropriate response is the one that teaches the client about his BAL and directs him to focus on his action and behaviors. In asking “Did you ask the judge to clarify his decision to make you come here?” the nurse seeks clarification from the client, which closes off the expression of feelings by changing the focus of the discussion. In stating “This reading means that you had consumed enough alcohol to put you close to the legal intoxication level. You were lucky because you just missed that level,” the nurse gives inaccurate information about the BAL. In responding “Well, the legal limit is much less than that, so you avoided a drunken driving charge by coming here. Seems to me that the judge treated you pretty leniently by allowing you to take refuge here. Don’t you agree?” the nurse gives opinions and is judgmental, then asks for agreement in a sarcastic style of communication. Test-Taking Strategy: Use the process of elimination and your knowledge of the subject, BAL. Recalling that in most states the legal alcohol limit is 0.08% will direct you to the correct option. Eliminate options that do not show use of therapeutic communication techniques. Review the BAL and therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Question 19 0 / 1 pts An adolescent client has graduated high school and is preparing to leave home to attend college. The adolescent is distressed about this life change. The nurse plans to implement crisis interventions, knowing that this situation is characteristic of which type of crisis? A situational crisis7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 26/116 Y You Answered ou Answered An individual crisis Correct Answer Correct Answer A maturational crisis An adventitious crisis Rationale: A maturational crisis involves the normal life transitions that produce changes in individuals and how they perceive themselves, their roles, and their status. A situational crisis occurs when a specific external event disturbs an individual’s psychological equilibrium. An adventitious crisis is an unpredictable tragedy that occurs without warning. An individual may experience crisis; however, there is no formal type of crisis known as “individual crisis.” Test-Taking Strategy: Use the process of elimination and your knowledge of the subject, various types of crises. Focus on the data in the question to direct you to the correct option. Review the description of the types of crises if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Question 20 1 / 1 pts A heroin addict who overdoses on the drug is brought into the emergency department. The client is having seizures, and the nurse notes that his pupils are constricted. Which intervention does the nurse anticipate that the emergency department health care provider will prescribe? Gastric lavage Intravenous fluid7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 27/116 Correct! Correct! Naloxone Ammonium chloride Rationale: An opioid antagonist such as naloxone would be prescribed to treat a heroin overdose to reverse central nervous system depression. Gastric lavage is used for oral overdose of or oral poisoning with certain substances. Intravenous fluid is a general intervention in many situations. Ammonium chloride is used to acidify the urine of a client who overdoses on amphetamines. Test-Taking Strategy: Focus on the subject, an overdose of heroin. Recalling that naloxone is an opioid antagonist will direct you to the correct option. Review this naloxone and the treatment for heroin overdose if you had difficulty with this question. Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Question 21 1 / 1 pts A client in a retirement center rings the night alarm and says to the nurse, “Look at this old man! He keeps breaking into my apartment! You’ve got to get him to stay out of here so I can sleep.” Which statement by the nurse would be most therapeutic? “Why not just throw him out yourself and lock up once and for all?” “Now, you know that you’re always seeing things and people at night who aren’t there.”7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 28/116 “This must be very troubling to you, but I can’t see the old man. Perhaps I could stay with you for an hour or so while you try to rest.” Correct! Correct! “I’m sure you’re very frightened right now. Do you recall my telling you that this is called sundowner syndrome? Go to sleep and he’ll leave your apartment.” Rationale: The most therapeutic nursing response is the one that expresses empathy and helps orient the client to reality. It also offers self, builds trust, and provides support for the client’s distress. In asking “Why not just throw him out yourself and lock up once and for all?” the nurse reinforces the hallucination and delusional thinking by responding as if the old man is really there. In stating “Now, you know that you’re always seeing things and people at night who aren’t there,” the nurse is patronizing and belittling in responding to the client’s concerns, a nontherapeutic communication. In responding “I’m sure that you’re very frightened right now. Do you recall my telling you that this is called sundowner syndrome? Go to sleep and he’ll leave your apartment,” the nurse is lecturing the client and giving advice, which is not therapeutic. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. The only option that addresses the client’s fears and feelings is the correct option. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Question 22 1 / 1 pts7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 29/116 A client with schizophrenia is seen seemingly talking to someone who isn’t there. Which nursing statement would be most therapeutic initially? “Today is my birthday. Would you like to go on an outing with my family?” “You need to wash up and get ready to go to supper in the cafeteria with the other clients now.” “I’ve noticed your eyes darting back and forth, and I wondered whether you might be hearing voices.” Correct! Correct! “You were telling me yesterday that your mother died last June of cancer. Can you tell me more about that?”7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 30/116 Rationale: The most therapeutic nursing statement is the one in which the nurse addresses the client’s behavior and asks whether the client is hearing voices. With this statement, the nurse also assesses the client’s behavior. If the client is hearing voices, the nurse prevents reinforcement of the hallucinatory thinking by telling the client that he or she does not hear them. In asking “Today is my birthday. Would you like to go on an outing with my family?” the nurse nontherapeutically changes the focus from the client. In stating “You need to wash up and get ready to go to supper in the cafeteria with the other clients now,” the nurse ignores the client’s obvious psychotic behavior and directs the client to socialize with others. Such an intervention is not usually positive because it floods the client with stimuli that may contribute to an escalation of psychotic behavior. In asking “You were telling me yesterday that your mother died last June of cancer. Can you tell me more about that?” the nurse uses distraction, summarization, and refocusing. Test-Taking Strategy: Note the strategic word “initially” and eliminate the options that are unrelated to the client’s behavior. Also, focus on the data in the question. The correct option is the only one that addresses the client’s behavior. Review care of the client who is hallucinating if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Question 23 1 / 1 pts A nurse brings a meal tray to a client with psychosis who is in his hospital room. The client refuses the meal and says, “I’m not eating any more poisoned food while I’m vacationing here. I’m starting on a fast to stay healthy and alive.” Which nursing intervention would be most appropriate initially? Taking the tray away and canceling all meals until further notice7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 31/116 Having the client eat with other clients in the community dining room Correct! Correct! Eating some of the food from the client s tray to prove that it isn t poisoned Telling the client that the psychiatrist will be called for a prescription for a tube feeding Rationale: Having the client eat with other clients in the community room decreases the amount of time in which the client can stay isolated and engage in suspicious thinking. Of the options provided, this would be the initial intervention. It does not guarantee that the client will eat but does reduce the client’s isolation time. Taking the tray away and canceling all meals until further notice and eating some of the food off the client’s tray to prove that it isn’t poisoned are both incorrect because they support the client’s delusional thinking. Telling the client that the psychiatrist will be called for a prescription for a tube feeding is incorrect because it is a premature action that would lead to a regressive struggle with the client and is also a threat to the client. Test-Taking Strategy: Note the strategic word “initially.” First eliminate the option in which the nurse threatens the client. From the remaining options, eliminate comparable or alike options that support the client’s delusional thinking, a nontherapeutic intervention. Review care of the client with psychosis if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Question 24 1 / 1 pts7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 32/116 A nurse caring for a client with schizophrenia is assessing the client’s ability to control distorted thought processes. Which finding indicates a positive outcome? The client is able to identify when hallucinations or delusions are real. The client can describe in detail the frequency and context of the hallucinatory and delusional behavior. The client can describe the hallucinations and delusions in detail and is able to interact with others and share in their delusional systems. The client can identify the recurrence of hallucinations, can refrain from responding to them, and reports a significant decrease in the incidence of hallucinations. Correct! Correct!7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 33/116 Rationale: Identifying the reoccurrence of hallucinations, refraining from responding to them, and reporting a significant decrease in the incidence of hallucinations are all positive client outcomes. Other positive outcomes include appropriately interacting with others, demonstrating thinking that is based in reality, and grasping others’ ideas. The other options are incorrect because they are not positive outcomes with regard to the client’s ability to control distorted thought processes and focus on the reality of the distorted thought processes. Test-Taking Strategy: Use the process of elimination. Focus on the subject, the client’s ability to control distorted thought processes. The correct option is the only one that identifies control. Review care of the client who is experiencing distorted thought processes if you had difficulty with this question. Cognitive Ability: Evaluating Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Evaluation Content Area: Mental Health Question 25 1 / 1 pts A client with schizophrenia says, “I feel like I’m rotting away inside and all of my organs are rusting.” Which type of delusion does the nurse identify in the client’s statement? Correct! Correct! Somatic Jealousy Persecution Idea of reference7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 34/116 Rationale: Somatic delusions are false beliefs that one’s body is changing in an unusual way, such as rusting or rotting away. The most therapeutic intervention in such a situation is to gain the client’s cooperation in taking the antipsychotic medication prescribed by the psychiatrist. A delusion of jealousy is the false belief that one’s significant other is being unfaithful. A delusion of persecution is the false belief that one is being singled out for harm by others. This usually takes the form of a plot by individuals in power against the person. A client subject to ideas of reference misconstrues trivial events and remarks so that he or she may attach personal significance to them. Test-Taking Strategy: Use the process of elimination and your knowledge of the subject, various types of delusions. Note the data in the question, and remember that the client is describing a physiological manifestation. This will direct you to the correct option. Review the different types of delusions if you had difficulty with this question. Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Assessment Content Area: Mental Health Question 26 1 / 1 pts A client with schizophrenia is attending a support group held by a clinic nurse and says to the nurse and the group, “I’ve been laid off from my job at the factory, and so have 300 other people, so I’ll have to get a new job. For now, there’s unemployment.” Which statement by the nurse would be most therapeutic at this time? “It seems that the stock market is responsible for mass unemployment in our factory-based city.” “I’m sorry to hear that you’ve lost your job. Why not make an appointment to come in and talk with me this week?”7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 35/116 “How do people feel about this loss of employment? Does anyone in the group who experienced this have any advice?” “Have other people in the group been feeling the job crunch this week? When changes like this occur, it’s best to increase the number of your appointments with me for a short time.” Correct! Correct! Rationale: The nurse is leading a support group for schizophrenic clients, so it is important to address every group member when possible and not single out one member for special attention. The correct option is openended, encourages group sharing of experiences and support, and teaches the members about the need to increase visits whenever schedules change abruptly and create stressful situations. In stating “It seems that the stock market is responsible for mass unemployment in our factory-based city,” the nurse changes the focus from feelings and experiences to intellectualize, a nontherapeutic intervention. In responding “I’m sorry to hear that you’ve lost your job. Why not make an appointment to come in and talk with me this week?” the nurse expresses sympathy rather than empathy and personalizes the invitation for an appointment that may cause jealousy among the other clients in the group. In asking “How do people feel about this loss of employment? Does anyone in the group who experienced this have any advice?” the nurse asks a question of the group that is off focus. Test-Taking Strategy: Focus on the environment of the question, a support group. The only option that addresses all members of the group is the correct option. It is also the umbrella option. Review the functions of support groups if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 36/116 Question 27 1 / 1 pts A client with schizophrenia arrives for a scheduled appointment with the mental health nurse. The nurse notes that the client’s hygiene is poor and that the client is having difficulty concentrating on what the nurse is saying and responding appropriately. Which nursing intervention would be most appropriate? Saying nothing and contacting the psychiatrist to sign a commitment order Saying, “I notice that you don’t seem to be caring for yourself. Are you taking your medication?” Correct! Correct! Giving the client his antipsychotic medication and asking him to return in the morning for a follow-up visit Asking, “Will you voluntarily admit yourself for a couple of days so that you can straighten out your medicine and thinking?”7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 37/116 Rationale: When the nurse’s observations indicate that the client is noncompliant with his medicine, the most appropriate intervention is the one in which the nurse makes observations and assesses noncompliance. Saying nothing and contacting the psychiatrist to sign a commitment order is inappropriate. Commitment proceedings may be necessary if the client is a danger to self or others. Giving the client his antipsychotic medication and asking him to return in the morning for a follow-up visit is inappropriate because the client needs assessment and intervention immediately. Waiting until the next morning does not meet the client’s immediate needs. In asking “Will you voluntarily admit yourself for a couple of days so that you can straighten out your medicine and thinking?” the nurse asks the client to enter the hospital voluntarily. This intervention is premature because further assessment of the client is needed. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that involve a delay in addressing the client’s needs. To select from the remaining options, focus on the data in the question and choose the one that addresses observations made by the nurse. Review care of the client with schizophrenia and observations that indicate medication noncompliance if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Question 28 1 / 1 pts A postpartum client says to the nurse, “Sometimes I hear voices telling me to kill my baby to save her all the heartache I’ve been through.” Which statement by the nurse would be most therapeutic? “The voices will disappear in a few weeks as your hormones stabilize.”7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 38/116 “This must be very distressing to you. Can you tell me more about the voices?” “It is so good that you shared your feelings and thoughts with me. I’m going to help you get immediate attention for your voices.” Correct! Correct! “You will want to tell the doctor about them when you visit him next week. He is very interested in these voices and will want to help you with them.” Rationale: The client is experiencing serious postpartum psychosis and command hallucinations. They require immediate medical attention and intervention for the protection of both the mother and her baby. In stating “The voices will disappear in a few weeks as your hormones stabilize,” the nurse disregards serious clinical manifestations. In responding, “This must be very distressing to you. Can you tell me more about the voices?” the nurse is trying to obtain additional data, but the client’s statement indicates a psychiatric emergency that requires immediate intervention. In stating, “You will want to tell the doctor about them when you visit him next week. He is very interested in these voices and will want to help you with them,” the nurse delays and refers the client to a psychiatrist 1 week from now, an intervention that may be too late for the mother and baby. Test-Taking Strategy: Focus on the data in the question, noting the words “voices telling me to kill my baby.” The only option that provides immediate attention to this serious statement is the correct option. Review interventions for the client who indicates the possibility of self-harm or harm to others if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Mental Health7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 39/116 Question 29 1 / 1 pts A client with schizophrenia exhibits confused and unintelligible speech. Which nursing statement would be most therapeutic? “Got it. The ‘blinks’ are ‘taking over’ the ‘bumpers.’” “I can’t understand what you’re saying. You have to talk more clearly!” “This morning you are participating in the tree-decorating ceremony for the unit.” Correct! Correct! “I can’t understand you. Are you asking me to stay with you while you eat supper?”7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 40/116 Rationale: The most therapeutic technique for assisting a client whose speech is confused and unintelligible is to emphasize what is happening in the here and now and involve the client in simple reality-based activities. “Got it. The ‘blinks’ are ‘taking over’ the ‘bumpers’” is unintelligible speech on the part of the nurse and reinforces the client's behavior. In stating “I can’t understand what you’re saying. You have to talk more clearly!” the nurse begins with an appropriate response, but demanding that the client speak more clearly is inappropriate. In responding “I can’t understand you. Are you asking me to stay with you while you eat supper?” the nurse is guessing at what the client has said. Test-Taking Strategy: Use knowledge of the subject, communication with a client using unintelligible speech, to assist you with the process of elimination. First eliminate the option that is unintelligible. Next eliminate the option that is demanding that the client speak more clearly. As you choose from the remaining options, remember that a client with schizophrenia who exhibits confusion and unintelligible speech should be involved in simple realitybased activities. Review care of the client with schizophrenia if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Question 30 1 / 1 pts A client with schizophrenia says to the nurse, “I keep getting these thoughts and hearing voices. They worry and consume me so that I can’t always stop myself like my doctor told me to.” Which intervention would the nurse suggest as a distraction technique? “Pretend that you’re on the phone and talk to the voices.” Correct! Correct! “Have you tried to count back from 100 or listen to music?”7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 41/116 “The next time this happens, try telling the voices to go away.” “Tell the voices that you will only listen to them just before you watch television at 8:30 in the evening.” Rationale: Distracting ways of coping with voices include reading aloud, describing an object in detail, listening to music, and watching television. Having the client try to count back from 100 or listen to music will assist in distraction. In the remaining options, the nurse suggests interacting techniques that reinforce the client’s belief that the voices are real. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that indicate that the voices are real. Review care of the client with schizophrenia who is hallucinating if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Question 31 1 / 1 pts A nurse is participating in a care planning conference for a client who is being treated for psychosis. Which step would be included during the stable or discharge phase of treatment? Evaluation of neurological status Use of directive communications with the client Administration of acute psychotropic medications Correct! Correct! Keeping the client active with hobbies, exercise, and work7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 42/116 Rationale: Desired outcomes for a psychotic client during the stable or discharge phase of treatment include maintenance of a consistent sleeping pattern; avoidance of caffeine and alcohol; maintenance of daily and weekly routines, including enjoyable activities; and a regular medication schedule. Evaluation of neurological status, the use of directive communications, and the administration of acute psychotropic medications with the client are all active-phase interventions. Test-Taking Strategy: Use the process of elimination and focus on the subject, the stable or discharge phase of treatment. First eliminate the option that contains the word “acute.” To select from the remaining options, focus on the subject. Evaluation of neurological status and use of directive communications with the client are part of the acute phase of treatment. Review interventions for the client with psychosis who is preparing for discharge if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Question 32 1 / 1 pts A client with schizophrenia is admitted to the inpatient psychiatric unit. The client is exhibiting clang associations, word salad, and loose associations. Which problem does the nurse recognize that the client is experiencing? Defensive coping Inability to cope effectively Sensory perception alterations Correct! Correct! Inability to communicate effectively7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 43/116 Rationale: Clang associations, word salad, and loose associations are language disturbances that indicate a client’s inability to communicate effectively. These manifestations are not associated with coping or sensory alterations. Test-Taking Strategy: Focus on the data in the question. Eliminate the comparable or alike options: Defensive coping is the same as inability to cope effectively. To select from the remaining options, recall that clang associations, word salad, and loose associations are signs of disturbed thought process and impaired verbal communication, which will direct you to the correct option. Review the characteristics of schizophrenia if you had difficulty with this question. Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Question 33 1 / 1 pts A 24-year-old client with schizophrenia says, “I was in college and suddenly I was hearing voices telling me I was no good and that I should jump off the bridge by our college. My parents came and got me when I called them. We thought that I had inadvertently taken drugs at a party or something. My psychiatrist says that if I can improve, I can return to college next semester.” Which guideline does the nurse plan to incorporate into teaching of the client and family about self-care on the client’s return to college? Compliance with the treatment regimen, immediate reporting of any relapse signs, avoidance of alcohol and drugs, and living a balanced lifestyle Correct! Correct!7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 44/116 Telling all friends about the illness so that they support the client s avoidance of alcohol and drugs and help the client maintain a balanced lifestyle Limiting college attendance to commuter status to maintain a supportive family group and avoiding drugs, alcohol, and the strain of socialization Compliance with treatment, immediate reporting of any relapse signs, avoidance of alcohol and drugs, and socialization with one supportive friend Rationale: Self-care guidelines for the client include compliance with the treatment regimen, immediate reporting of any relapse signs, avoidance of alcohol and drugs, and living a balanced lifestyle. Telling all friends about the illness so that they can support the client’s avoidance of alcohol and drugs and help the client maintain a balanced lifestyle is incorrect. Although the closest supportive friends need to know and understand the illness, not everybody does. Limiting college attendance to commuter status to maintain a supportive family group and avoiding drugs, alcohol, and the strain of socialization is incorrect. Not allowing the client to be independent and follow a normal growth and development pattern would retard the client’s growth. Socializing with one supportive friend is incorrect because it is best to bring as many supportive persons to the client as possible. Test-Taking Strategy: Use the process of elimination and focus on the data in the question and the subject, selfcare. Eliminate the options that contain the words “one,” “all,” and “limiting.” Also note that the correct option is the umbrella option. Review care of the client with schizophrenia if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Teaching and Learning Content Area: Mental Health7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 45/116 Question 34 0 / 1 pts A client with schizophrenia in the psychiatric inpatient unit is yelling, “The CIA is trying to kill me. I know they’re plotting to kill me so they can overthrow the government.” On the basis of the client’s statement, which clinical manifestation would the nurse document in the client record? Demonstrates paranoia Exhibits ideas of reference Correct Answer Correct Answer Evidence of persecutory delusions Y You Answered ou Answered Evidence of ideas of somatic delusions Rationale: A persecutory delusion is the false belief that one is being singled out for harm by others, generally in the form of a plot by other people against the client. Paranoia is an intense and strongly defended irrational suspicion. An idea of reference is the misconstruing of trivial events in order to give them personal significance. A somatic delusion is the false belief that the body is changing in an unusual way (e.g., rotting inside). Test-Taking Strategy: Use the process of elimination. Focus on the information in the question, focusing on the client’s statement and note the relationship between the words “trying to kill me” in the question and “persecutory” in the correct option. Review the characteristics of schizophrenia if you had difficulty with this question. Cognitive Ability: Understanding Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Question 35 1 / 1 pts7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 46/116 A client experiencing mania who tends to be manipulative says angrily, “You had better let me out of here, or I’m going to call my lawyer. My boss is good friends with the owners of this tin-pot place you call a ‘mind holism respite.’” Which statement by the nurse would be most therapeutic? “When you can talk to me without yelling and being aggressive, I’ll be happy to speak with you.” “Just get your anger out with me, because we’re not going to allow you be discharged until you calm down.” “Do threats and name-calling usually work for you? Do people tend to listen to you and do as you order them to?” “I know that you feel that you’re doing your very best right now, but you are yelling. Take some time out and some deep breaths, and I’ll speak to you in half an hour.” Correct! Correct!7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 47/116 Rationale: Anger is an emotional response to the perception of frustration of desires, threat to one’s needs (emotional or physical), or a challenge. It reflects rage, hostility, and the potential for physical or verbal destructiveness. With manipulative clients, solutions that provide options and empathy work best. An authoritarian style in which the nurse labels aggression is inappropriate and is not effective with such clients. Additionally, the remaining options may further anger the client and escalate the client’s behavior. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that may further anger the client. Also note that the correct option provides praise to the client and provides an option for dealing with the client’s behavior. Review interventions to defuse anger if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Question 36 1 / 1 pts A client in a mental health unit gets into a fight with another client over the use of the public telephone on the unit. The client is accused of making two telephone calls and staying on the telephone for 1 hour. Which intervention by the nurse would be most therapeutic? Taking telephone privileges away from both clients for the day and giving them time-outs in their rooms Saying to the clients, “Okay, this is the last straw. Neither of you may use the telephone until tomorrow, and then only with a nurse timing you.”7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 48/116 Saying to the clients, “Go to your rooms, both of you. I don’t want to hear anything more about the telephone on this unit for at least 2 hours.” Saying to the clients, “You may each use the phone for 10 minutes. I will time the calls for both of you. Do you both agree to abide by my decision?” Correct! Correct! Rationale: The most therapeutic intervention is the one in which the nurse gives an alternative solution and asks for the clients’ cooperation. If this approach fails, the nurse must eliminate the phone privilege for both clients and give time-outs to deescalate the situation. Taking telephone privileges away from both clients for the day and giving them time-outs in their rooms is nontherapeutic because the nurse is not being empathetic. In stating “Okay, this is the last straw. Neither of you may use the telephone until tomorrow, and then only with a nurse timing you,” the nurse displays anger and is nontherapeutic in punishing the clients. In responding “Go to your rooms, both of you. I don’t want to hear anything more about the telephone on this unit for at least 2 hours,” the nurse is nontherapeutically authoritarian and does not provide empathy. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options in that the nurse acts in a punishing and authoritarian way. Also, note that the correct option is the only option that provides an alternative solution for both clients. Review measures for dealing with an angry client if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Question 37 1 / 1 pts7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 49/116 A nursing instructor enters a classroom to begin class and finds two students yelling and physically assaulting each other. Which intervention by the instructor would be most appropriate? Walking out of the classroom and asking the secretary to call security, then telling all of the students to leave and go to the nursing laboratory Getting the class to leave with her and sending everyone to the nursing laboratory, then calling security to the classroom and reentering to observe what is happening with the two students. Telling the class, “Take a break. I’ll come and get you to restart class as soon as I can,” then closing the classroom door, refusing to let anyone else in, and asking a passing instructor to get security Telling the class to go to the nursing laboratory at once, then asking a student to tell the nursing secretary to have security come to the classroom, and asking the students who are fighting to stop fighting and take their seats Correct! Correct!7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 50/116 Rationale: The first concern is to ensure student safety, so in the correct option, the students are directed to go to the nursing laboratory. Someone is asked to notify security, and then the instructor determines whether the students who are fighting can obey the direction to stop and take a seat. Leaving the classroom without attempting to verbally direct the students to stop fighting results in an unsafe environment for the students who are fighting. Although closing the classroom door might be helpful in discouraging other students from watching the fight, it is not generally considered a safe intervention to bar access to an exit when violence has erupted. Test-Taking Strategy: Focus on the information in the question, and recall that safety is the priority. The correct option is the only one that provides safety to all involved. Review interventions for a violent situation if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Question 38 1 / 1 pts A student calls the campus crisis hotline and tells the nurse, “I went out to a sorority party last week and drank too much. Someone raped me, but when I told my folks about it, they acted like it was my fault. I feel so dirty and used.” Which statement by the nurse would be most therapeutic? “Would you come in to talk with me in the strictest confidence?” “I believe that you can feel a lot better about yourself. Won’t you come in to see me tomorrow?”7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 51/116 “Parents always feel that their daughters could never be raped. I could talk to them for you, if you’ll let me.” “You’ve had an awful experience, but it’s not your fault that it happened. Can you come in and talk to me about it in more detail?” Correct! Correct! Rationale: Rape is vaginal or anal penetration against the victim’s will and consent. The student is in crisis and needs counseling. Her call seems to be the result of her being unable to turn to her parents as she might have been able to in the past. The nurse needs to let the student know that the rape was not her fault. Many students overdrink but are not raped just because they were inebriated. By asking “Would you come in to talk with me in the strictest confidence?” the nurse assures confidentiality, but this option is nontherapeutic because a bridge of trust has not yet been established with the client. In responding “I believe that you can feel a lot better about yourself. Won’t you come in to see me tomorrow?” the nurse offers opinions on outcomes and delays treatment, which is nontherapeutic. In responding “Parents always feel that their daughter could never be raped. I could talk to them for you, if you'll let me,” the nurse lectures the student on why her parents are not supportive without ever having met them. This answer is nontherapeutic and insensitive. Test-Taking Strategy: Use the process of elimination and your knowledge of therapeutic communication techniques. The correct option, the umbrella option, acknowledges the client’s experience, informs the client that the rape was not her fault, expresses support, and provides immediate treatment. Review interventions for the client who is a victim of abuse if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 52/116 Question 39 1 / 1 pts A psychiatric nurse is playing a card game with a client in the day room. The client states to the nurse, “The voice in my head is telling me that you’re cheating.” Which response by the nurse is therapeutic? Correct! Correct! “I do not hear any voices. Has the voice said anything else?” “Is the voice telling you to do anything?” “It isn't possible for people to hear voices in their head.” “I don't believe that you are hearing voices.” Rationale: When caring for a client experiencing delusions or hallucinations, the nurse should listen to the client, present reality, and collect more data regarding the content of the delusion and/or hallucination. Stating “I do not hear any voices. Has the voice said anything else?” is correct because it presents reality and collects more data from the client. Although stating “Is the voice telling you to do anything?” collects more data, it does not present reality. Stating “It isn't possible for people to hear voices in their head” and “I don’t believe that you are hearing voices” are nontherapeutic and do not address the needs or feelings of the client. Test-Taking Strategy: Use therapeutic communication techniques to answer this question. Recalling that it is important to both present reality and collect more data from a client actively experiencing delusions and/or hallucinations will assist in directing you to the correct option. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 53/116 Question 40 1 / 1 pts A client says to the nurse, “I’m really phobic about flying, so my husband and I always drove or took the train everywhere. Now he’s been offered a big job in Europe, and if I don’t get over this and fly with him, he says we’re done. I’ll be left to bring up our three children by myself.” Which statement by the nurse would be therapeutic? “No problem. You can be hypnotized to sleep through your trip.” “I’m interested that it took his threat of leaving you to motivate you to seek help.” “You seem more anxious and afraid of raising three children alone than of flying.” “I can teach you strategies to help master your panic. An antianxiety medicine would also help you.” Correct! Correct!7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 54/116 Rationale: A phobia is a persistent, irrational fear of a specific object, activity, or situation that leads to a desire for avoidance or actual avoidance of the object, activity, or situation. The nurse can teach strategies, such as relaxation training and thought-stopping, to help the client master her anxiety. There are also medications that the psychiatrist can prescribe to help ease the client’s phobia. In stating “No problem. You can be hypnotized to sleep through your trip,” the nurse provides false reassurance and belittles the client’s worries and fears. In responding “I’m interested that it took his threat of leaving you to motivate you to seek help,” the nurse uses a nontherapeutic change of subject that can only increase the client’s anxiety and fear. This response also lowers the client’s trust in her relationship with the nurse. In stating “You seem more anxious and afraid of raising three children alone than of flying,” the nurse changes the subject. Test-Taking Strategy: Use the process of elimination and therapeutic communication techniques. Eliminate the comparable or alike options that do not focus on the client’s concern or provide false reassurance. The correct option is focused on the client’s concern and provides a reasonable solution. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Question 41 1 / 1 pts A nurse is trying to deescalate aggressive behavior exhibited by a client with schizophrenia. Which nursing action would be contraindicated in this situation? Being assertive with the client Negotiating options with the client7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 55/116 Maintaining a nonaggressive posture Standing close to the client and telling the client that the behavior is unacceptable Correct! Correct! Rationale: To deescalate aggressive behavior, the nurse should maintain calm and a nonaggressive posture. The nurse should also give the client clear instructions that are brief and assertive and negotiate options with the client. Negotiation of options allows the client to feel that he or she has some room in making decisions. The nurse needs to maintain personal space and should not stand closer than about 8 feet from the client, which would convey a threatening message. Test-Taking Strategy: Focus on the subject, deescalation of aggressive behavior, and note the strategic word “contraindicated.” Visualize each of the options in terms of how it might protect or threaten the client. This will direct you to the correct option. If you had difficulty with this question, review measures to deescalate aggressive behavior. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Question 42 1 / 1 pts A client is scheduled to undergo electroconvulsive therapy (ECT). Which client concern is of the highest priority? Fear Anxiety Distorted body image7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 56/116 Correct! Correct! Risk for impaired breathing Rationale: NPO (nothing by mouth) status for 6 to 8 hours before a procedure, removal of dentures during the procedure, and administration of medication as prescribed to diminish oral secretions are all safeguards against aspiration during ECT. Although fear and anxiety could also be concerns, they are not the most important ones. There is no reason to infer that distorted body image is a consideration. Test-Taking Strategy: Use Maslow’s Hierarchy of Needs theory to answer the question. Physiological needs are the priority, so select the option that addresses these needs. Additionally, remember the ABCs—airway, breathing, and circulation. Airway is the concern with the risk of aspiration. If you had difficulty with this question, review procedures related to ECT. Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Question 43 1 / 1 pts The mother of a child who is taking methylphenidate hydrochloride tells the school nurse that she is administering an over-the-counter (OTC) cough syrup to her son. Which response by the nurse would be appropriate? “His cough could be a side effect of the Ritalin.” “Your son should never take any medicine, even if it’s OTC.” “You may administer a small amount of OTC cough syrup without a problem, but not for more than 3 days.”7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 57/116 “I think that you should stop giving this medicine to your son until I can check its content with the pharmacy.” Correct! Correct! Rationale: When a client is taking methylphenidate hydrochloride, no OTC medications should be administered without the approval of the pharmacist or health care provider. Such medications could contain caffeine or pseudoephedrine, which must be avoided. In stating “Your son should never take any medicine, even if it’s OTC,” the nurse is lecturing and belittling. In stating “His cough could be a side effect of the Ritalin” or “You may administer a small amount of OTC cough syrup without a problem, but not for more than 3 days,” the nurse provides inaccurate information. Test-Taking Strategy: Use the process of elimination. Eliminate the option that contains the closed-ended word “never.” To select from the remaining options, recall that OTC medications should not be taken by clients taking prescription medications without the approval of the health care provider. Review the contraindications associated with methylphenidate hydrochloride if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Question 44 1 / 1 pts A nurse notices a client who has paranoia staring at the nurse during a conversation. The client then begins to fidget and gets up to pace around the room. Which action(s) by the nurse would be beneficial? Allowing the client to pace Escorting the client to a quiet room7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 58/116 Changing the conversation to a less threatening subject Sharing the observation with the client and helping the client recognize and acknowledge his or her feelings Correct! Correct! Rationale: Sharing observations with clients may help them recognize and acknowledge their feelings. Moving the client to a quiet room or changing the subject will not help a client recognize his or her behaviors and feelings. Allowing clients to pace provides no assistance and may lead to their becoming out of control. Test-Taking Strategy: Use the process of elimination and therapeutic communication techniques. Eliminate the options that do not address the client’s behavior. Remembering that the sharing observations with the client and helping the client recognize and acknowledge his or her feelings will be of help to the client who is experiencing paranoid behaviors. Review care of the client with paranoia if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Question 45 1 / 1 pts A nurse working in a mental health unit reads a client’s medical record and notes documentation that the client has been experiencing flashbacks. The nurse interprets this as a classic sign of which disorder? Depression Schizophrenia Correct! Correct! Posttraumatic stress disorder7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 59/116 Obsessive-compulsive disorder Rationale: Flashbacks are the classic manifestation of posttraumatic stress disorder, or PTSD, and are not associated with depression, obsessive-compulsive disorder, or schizophrenia. Test-Taking Strategy: Use the process of elimination and note the strategic word “flashbacks.” Review each option and think about the manifestations of each disorder to answer correctly. Review the manifestations of each of PTSD if you had difficulty with this question. Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Question 46 1 / 1 pts A client arrives in the emergency department in a crisis state. The client demonstrates signs of profound anxiety and is unable to focus on anything but the object of the crisis and the impact on herself. The nurse plans to focus the initial data collection on which matter? Sources of support The object of the crisis The client’s coping mechanisms Correct! Correct! The physical condition of the client7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 60/116 Rationale: The initial priority in the nursing care of a client in a crisis state is to collect data on the physical condition, potential for self-harm, and potential for harm to others. Once these questions have been answered and the appropriate interventions have been initiated, the nurse may proceed in providing psychosocial care. Test-Taking Strategy: Use Maslow’s Hierarchy of Needs theory. Physiological needs take priority over other needs. The correct option is the only option that addresses a physiological need. Review care of the client in crisis if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Question 47 1 / 1 pts A nurse has been closely observing a client who has been displaying aggressive behaviors and notes that the client’s aggressiveness is escalating. Which nursing intervention would be least helpful to this client at this time? Correct! Correct! Initiating confinement measures Acknowledging the client’s behavior Assisting the client to an area that is quiet Maintaining a safe distance with the client7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 61/116 Rationale: During the escalation period, the client’s behavior is moving toward loss of control. Nursing actions include taking control, maintaining a safe distance, acknowledging the behavior, moving the client to a quiet area, and medicating the client as appropriate. It is not appropriate during this period to initiate confinement measures; this action is most appropriate during the crisis period. Test-Taking Strategy: Note the strategic words “least helpful,” and focus on the data in the question. Nursing actions will vary depending on the level of aggressive behavior that the client is exhibiting. Knowledge of these levels and the appropriate nursing actions is required to answer this question. However, focusing on the strategic words will direct you to the correct option. Review care of the client exhibiting aggressive behavior if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Question 48 0 / 1 pts A nurse is assigned to care for a client experiencing a crisis. What is the appropriate initial nursing intervention for this client? Correct Answer Correct Answer Providing authority and action Displaying an attitude of detachment and efficiency Providing hope and reassurance that the crisis is temporary Demonstrating confidence in the client’s ability to deal with the crisis Y You Answered ou Answered7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 62/116 Rationale: A crisis is an acute time-limited state of disequilibrium resulting from situational, developmental, or societal sources of stress. A person in this state is temporarily unable to cope with or adapt to the stressor with the use of previously successful problem-solving methods. Someone who intervenes in this situation (the nurse) takes over for the client who is not in control and devises a plan (action) to secure and maintain the client’s safety. The nurse then works collaboratively with the client, demonstrating confidence in the client’s ability to cope and providing reassurance that the crisis is temporary. Displaying an attitude of detachment is inappropriate. Test-Taking Strategy: Use the process of elimination and note the strategic word “initial.” The client who experiences a crisis is in acute disequilibrium. Remember, in a crisis, an authority figure must emerge to take action. Review crisis intervention and the nurse’s responsibilities if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Question 49 1 / 1 pts A home care nurse makes a visit to a client with a diagnosis of depression. The nurse finds the client unconscious on the floor, and an empty bottle of a prescribed tricyclic antidepressant is lying near the client. What action must the nurse take immediately? Inducing vomiting Correct! Correct! Calling an ambulance Administering syrup of ipecac7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 63/116 Counting the pills remaining in the bottle Rationale: An overdose of a tricyclic antidepressant can be fatal, regardless of the amount ingested. Serious lifethreatening symptoms may develop after an overdose. Immediate emergency medical attention and cardiac monitoring are needed in the event of an overdose of a tricyclic antidepressant. The nurse would not induce vomiting or administer anything by way of the oral route if the client is unconscious. Counting the remaining pills provides no useful information and delays necessary and immediate intervention. Additionally, the question notes that the bottle of pills is empty. Test-Taking Strategy: Use the process of elimination and note the strategic words “immediately.” Eliminate the option that delays measures to provide immediate treatment and provides no useful information (i.e., counting the pills remaining in the bottle). Induction of vomiting or administration of an oral substance would not be performed in a client who is unconscious, so eliminate these options as well. Review immediate measures required for an overdose of a tricyclic antidepressant if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Question 50 1 / 1 pts Which client is at the highest risk for suicide? A 24-year-old man who is angry with his family A 71-year-old man with mild depression and social withdrawal7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 64/116 A 75-year-old woman with severe depression and disabling arthritis Correct! Correct! A 30-year-old newly divorced woman who has custody of her children Rationale: An individual with a terminal or crippling illness is at high risk for suicide. Other high-risk groups include adolescents, drug abusers, individuals who have experienced social problems or recent losses or have little or no social support, and individuals with a history of suicide attempts and a suicide plan. Test-Taking Strategy: Note the strategic words “highest risk.” Note that the correct option contains the words “severe” and “ disabling.” If you are unfamiliar with the risk factors and groups at risk for suicide, review this content. Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Question 51 1 / 1 pts A client brought to the emergency department by the police after being mugged is extremely agitated, trembling, and hyperventilating. What is the appropriate initial nursing action? Correct! Correct! Staying with the client Teaching the client how to relax Asking the client questions about the mugging7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 65/116 Allowing the client to be alone in a room at the end of the emergency department corridor, where it is quiet Rationale: This client is in a severe state of anxiety. When a client is in a severe or panic state of anxiety, it is critical for the nurse to remain with the client. Processing the anxiety (e.g., asking questions) at this point will further increase the client’s anxiety. The client in a severe state of anxiety is not able to learn relaxation techniques. Test-Taking Strategy: Note the data in the question and remember that the client is exhibiting a severe level of anxiety. Remember to use therapeutic techniques. The best technique in this situation is to remain with the client. If you are unfamiliar with the symptoms of the different levels of anxiety and the interventions that are indicated, review this information. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Question 52 1 / 1 pts A woman is brought to the emergency department after an assault. She presents with complaints of dizziness, dyspnea, visual disturbance, and motor tension with hyperactivity. Which level of anxiety does the nurse recognize in the client’s presentation? Mild Panic Correct! Correct! Severe Moderate7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 66/116 Rationale: A client who has severe anxiety complains of dizziness, dyspnea, and visual disturbances and exhibits motor tension with hyperactivity. A client with mild anxiety is alert and attentive. A client with moderate anxiety experiences a sense of helplessness, apprehension, irritability, and vigilance. A client in panic experiences chest pain and a feeling of impending doom or death. Test-Taking Strategy: Note the data in the question regarding the client’s symptoms. Also, use your knowledge of the subject, levels of anxiety, to answer the question. Remember, a client who has severe anxiety complains of dizziness, dyspnea, and visual disturbances and exhibits motor tension with hyperactivity. Review the signs and symptoms associated with each level of anxiety if you had difficulty with this question. Cognitive Ability: Understanding Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Question 53 1 / 1 pts A nurse is monitoring a client who is in seclusion. The nurse determines that it is safe for the client to come out of seclusion when the client makes which statement? “I need to go to the bathroom.” Correct! Correct! “I’m no longer a threat to myself or others.” “I want to be alone for a while in my own room.” “I can’t breathe in here. The walls are closing in on me.”7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 67/116 Rationale: The client in seclusion must be assessed at regular intervals (usually every 15 to 30 minutes) for fulfillment of physical needs, safety, and comfort and should be released from seclusion as soon as possible, provided that safety has been ensured. The statement “I'm no longer a threat to myself or others” indicates that it may be safe to remove the client from seclusion. The statement “I need to go to the bathroom” indicates a physical need that could be met with a urinal or bedpan, if necessary. It does not indicate that the client has calmed down enough to leave the seclusion room. The statement “I want to be alone for a while in my own room” could be an attempt to manipulate the nurse. It gives no indication that the client will control him or herself when alone in his or her room. The statement “I can’t breathe in here. The walls are closing in on me” indicates the need for supportive communication or possibly a prescribed medication. It does not necessitate the discontinuation of seclusion. Test-Taking Strategy: The subject of the question specifically relates to safety. Use the process of elimination to answer the question. Thinking about the purpose of seclusion will assist in directing you to the correct option. Review seclusion procedures if you had difficulty with this question. Cognitive Ability: Evaluating Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Evaluation Content Area: Mental Health Question 54 1 / 1 pts A nurse is preparing a discharge plan for a client who has attempted suicide. The nurse understands that the plan of care should focus on which aspect? Follow-up appointments Providing the hospital phone number7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 68/116 Correct! Correct! Contracts and immediate available crisis resources Encouraging the family to always be with the client Rationale: Crises may occur between appointments. Contracts help make clients feel responsible for keeping their promises, giving them a feeling of control. Encouraging the family to always be with the client is unrealistic. Follow-up appointments and providing phone numbers will not ensure immediate crisis intervention. Test-Taking Strategy: The subject of the question is the availability of immediate resources for the client when needed. Eliminate the option that contains the closeended word “always.” Next, eliminate the options that will not necessarily provide immediate resources. Also note the strategic word “immediate” in the correct option. Review discharge planning for a client who has attempted suicide if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Question 55 1 / 1 pts A nurse observes that a client is pacing back and forth. The nurse asks the client how she is feeling, and the client responds by telling the nurse that she feels “out of control!” Which intervention is most appropriate initially to maintain a safe environment? Restraining the client Placing the client in seclusion Continuing to monitor the client7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 69/116 Moving the client to a quiet room and talking about her feelings Correct! Correct! Rationale: The anxiety symptoms demonstrated by this client require some form of intervention. Moving the client to a quiet place decreases environmental stimuli, and talking gives the nurse an opportunity to identify the cause of the client’s feelings and determine the appropriate interventions. Seclusion or restraint is not appropriate. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options (restraint and seclusion). From the remaining options, select the option that addresses the client’s feelings. Additionally, note that the final incorrect option delays necessary intervention. Remember, the client’s feelings are most important. Review interventions for a client who feels out of control if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Question 56 1 / 1 pts A nurse employed in an emergency department is assisting in caring for an adult client who is a victim of family violence. Which priority instruction does the nurse include in the discharge plan? Calling the police Self-defense classes Correct! Correct! The locations of shelters The importance of leaving the violent situation7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 70/116 Rationale: Tertiary prevention of family violence includes assisting the victim after abuse has occurred. The nurse should provide the client with information on where to turn for help. This includes a specific plan for removing oneself from the abuser and information on escaping, hotlines, and shelter locations. An abused person is usually reluctant to call the police. Teaching the victim to fight back is not the appropriate action for a client dealing with a violent person. Explaining the importance of leaving the violent situation does not provide the client with ways to seek assistance and shelter. Test-Taking Strategy: Use the process of elimination and note the strategic word “priority.” Focus on the subject of the question, the provision of a safe environment for the client. Use Maslow’s Hierarchy of Needs theory to find the correct option. If you had difficulty with this question, review nursing measures for a victim of family violence. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Mental Health Question 57 1 / 1 pts A nurse is caring for a client who has been identified as a victim of physical abuse. Which action is the priority as the nurse plans care for the client? Notifying the caseworker of the situation Adhering to mandatory abuse reporting laws Correct! Correct! Removing the client from any immediate danger Obtaining treatment for the abusing family member7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 71/116 Rationale: Whenever the abused client remains in the abusive environment, priority must be placed on determining whether the person is in any immediate danger and, if so, taking emergency action to remove the client from the situation. Notifying the caseworker of the situation, adhering to mandatory abuse reporting laws, and obtaining treatment for the abusing family member may be appropriate interventions but are not the priority. Test-Taking Strategy: Note the strategic word “priority.” Use Maslow’s Hierarchy of Needs theory, remembering that if a physiological need is not present, then safety is the priority. This should direct you to the correct option, the only one that directly addresses client safety. Review care of the client who is a victim of physical abuse if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Mental Health Question 58 1 / 1 pts A nurse in the emergency department is helping care for a young female survivor of sexual assault. The client’s physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, confused, and, at times, physically immobile. The nurse interprets these behaviors in which way? These are signs of depression. Correct! Correct! These are normal reactions to a devastating event. This is indicative of the need for hospital admission. This is evidence that the client is at high risk for suicide.7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 72/116 Rationale: The symptoms noted in the question indicate a normal reaction to an intensely difficult crisis event. Although the client’s initial reactions may be predictive of later problems, they do not constitute an abnormal initial response (e.g., depression, need for hospital admission, high suicide risk). Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that present abnormal reactions. Remember, during the acute phase of the rape crisis (sexual assault), the client may display a wide range of emotional and somatic responses. If you had difficulty with this question, review normal and abnormal client responses to dealing with devastating crisis events. Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Question 59 1 / 1 pts A nurse preparing to admit a client with obsessive-compulsive disorder (OCD) to the mental health unit observes the client for certain characteristic behaviors. What are they? Hostility Correct! Correct! Inflexibility Adaptability Extreme fear7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 73/116 Rationale: Inflexible behavior is characteristic of the client with OCD. Clients are not usually hostile unless they are prevented from performing the obsession or compulsion, because that is what eases the anxiety. Extreme fear, hostility, and adaptability are not characteristics of OCD. Test-Taking Strategy: Use knowledge of the subject, behavior associated with OCD, to assist you with the process of elimination. Recalling that the client with OCD performs certain acts over and over as a means of easing anxiety will direct you to the correct option. Review the characteristics of OCD if you had difficulty with this question. Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Question 60 1 / 1 pts A client has just been admitted to the mental health unit with a diagnosis of obsessive-compulsive disorder. The nurse observes the client for compulsive behavior involving which repetitive behaviors? Fears Correct! Correct! Actions Thoughts Delusions7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 74/116 Rationale: A compulsion is a repetitive act, whereas an obsession is a repetitive thought. A phobia is a repetitive fear, and delusions are characteristic of schizophrenia. Test-Taking Strategy: Use the process of elimination and note the strategic words “compulsive behavior” in the question. This tells you that the correct option is something that can be observed by the nurse and will direct you to the correct option. Review the characteristics of obsessive-compulsive disorder if you had difficulty with this question. Cognitive Ability: Understanding Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Question 61 1 / 1 pts A client with obsessive-compulsive disorder who continually cleans her room with paper towels becomes enraged with her roommate for throwing the package of paper towels into the waste basket, begins to yell, and slaps the roommate. Which action would the nurse take first? Restraining the client Filling out an incident report Correct! Correct! Removing both clients to safe locations Calling the hospital’s risk-management department7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 75/116 Rationale: The first responsibility of the nurse is to ensure the safety of all clients. Removing each client to a safe location is the only option that fulfills the needs of both of the clients in the question. The other actions are either contraindicated (i.e., restraining the client) or are of lesser priority (i.e., filling out an incident report, which may not be indicated, depending on the level of injury to the second client, and calling the hospital’s risk-management department). Test-Taking Strategy: Use the process of elimination and note the strategic word “first.” Use Maslow’s Hierarchy of Needs theory, and recall that if a physiological need does not exist, then safety is the priority. This will direct you to the correct option. Also note that the correct option fulfills the needs of both clients in the question. Review methods for dealing with an aggressive client if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Question 62 1 / 1 pts A nurse is participating in a care planning conference for a client with obsessive-compulsive disorder (OCD). Which does the nurse expect to see as the focus of care? Group therapy Recreational therapy Correct! Correct! Reducing the client’s anxiety Stopping the client’s behavior immediately7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 76/116 Rationale: The focus of care will be reducing the client’s anxiety because OCD is a type of anxiety disorder. Group and recreational therapy may eventually reduce the anxiety, but the focus should be primarily on anxiety reduction. Stopping the client’s behavior immediately would likely increase the client’s anxiety level. Test-Taking Strategy: Use the process of elimination and note the strategic words “focus of care.” Eliminate comparable or alike options such as group and recreational therapy. The nontherapeutic option can also be eliminated. Review the care of the client with OCD if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Question 63 1 / 1 pts A moderately depressed client who was admitted to the mental health unit 2 days ago suddenly begins smiling and reports that the crisis is over. The client says to the nurse, “I’m finally cured.” The nurse interprets this behavior as a cue to modify the treatment plan by taking which action? Suggesting a reduction of medication Allowing increased in-room activities Correct! Correct! Increasing the level of suicide precautions Allowing the client off-unit privileges as necessary7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 77/116 Rationale: A client who is moderately depressed and has only been hospitalized for 2 days is very unlikely to have had such a dramatic cure. When a depressed mood suddenly lifts, it is likely that the client has made the decision to harm himself or herself. It is at this time that the client has the energy to perform the act. Therefore suicide precautions are necessary to keep the client safe. The other interventions will not provide the necessary safety precautions. Test-Taking Strategy: Use the process of elimination, and focus on the data in the question. Eliminate comparable or alike options that support the client’s notion that a cure has been effected. Safety is of the utmost importance now, so the correct option is the one that provides a safe action. Review care of the client with depression if you had difficulty with this question. Cognitive Ability: Analyzing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Mental Health Question 64 1 / 1 pts A nurse employed in a mental health unit is reviewing the work schedule. At what time does the nurse expect that additional client safety precautions will be provided? Day shift Weekdays Correct! Correct! Weekends 7 to 10 a.m.7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 78/116 Rationale: Because there is less availability of nursing staff on the weekends, risk to client safety increases, necessitating extra attention on the part of staff. There is often less availability of staff during shift changes as well. The nurse should increase precautions at these times. The night shift is also a high-risk time. Test-Taking Strategy: Use the process of elimination. The nurse would anticipate that periods with less supervision of the clients are times of increased risk to client safety. Eliminate the comparable or alike options that refer to times when more staff are usually available. This will direct you to the correct option. Review the guidelines for safety of the client with a mental illness if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Mental Health Question 65 1 / 1 pts An adolescent is returning home after an acute psychiatric hospitalization for a suicide attempt. Which strategy will be least effective in preparing the client for discharge? Encouraging the sharing of feelings Correct! Correct! Suggesting that the client’s mother quit her job Identifying the family’s strengths and weaknesses Offering and providing the family options and resources7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 79/116 Rationale: Suggesting that the client’s mother quit her job is clearly the least effective option because it disrupts family processes. Encouraging the sharing of feelings, identifying the family’s strengths and weaknesses, and offering and providing the family options and resources are helpful ways of enhancing the family processes. Test-Taking Strategy: Use the process of elimination and note the strategic words “least effective.” Eliminate the comparable or alike options that identify therapeutic and positive measures. This will direct you to the correct option. Review care of the client at risk for suicide if you had difficulty with this question. Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Question 66 1 / 1 pts A client is admitted to the psychiatric unit after a serious suicide attempt involving a drug overdose. Which is the priority nursing intervention? Correct! Correct! Remain with the client at all times. Request that a family member remain with the client at all times. Remove the client’s clothing and dress the client in a hospital gown. Place the client in a seclusion room from which all potentially dangerous articles have been removed.7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 80/116 Rationale: Drug overdose constitutes a serious suicide attempt. The plan of care must comprise actions that will promote the client’s safety. Constant observation by a staff member who is never less than an arm’s length away is the best action. Requesting that a family member remain with the client at all times, removing the client’s clothing and dressing the client in a hospital gown, and placing the client in a seclusion room from which all potentially dangerous articles have been removed are all inappropriate actions. It is not a family member’s responsibility to safeguard the client. Removing one’s clothing does not ensure safety, and it minimizes the client’s dignity. Seclusion is used as a last resort for clients who are aggressive or violent and a threat to self or others. Test-Taking Strategy: Note the strategic word “priority.” Eliminate the options that use the close-ended word “all.” From the remaining options, select the option that involves constant supervision in this critical situation. Review care of the client at risk for suicide if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Question 67 1 / 1 pts A nurse working with a sexual assault survivor in a clinic setting is assisting with the development of a plan of care for the client. Which short-term initial goal is most appropriate? The client will care for her own physical wounds. Correct! Correct! The client will verbalize her feelings about the event. The client will identify an appropriate treatment plan.7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 81/116 The client will resolve feelings of fear and anxiety related to the rape trauma. Rationale: A good initial short-term goal is verbalization of feelings about the event by the client. It is the nurse’s responsibility to treat the client’s physical wounds and provide information to her about the treatment plan. Resolution of feelings of fear and anxiety is a long-term goal. Test-Taking Strategy: Note the strategic words “short-term initial goal.” Use the process of elimination, considering the reality of the option statement and the client’s ability initially. This will direct you to the correct option. Review realistic goals for a client who is a survivor of sexual assault if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Question 68 1 / 1 pts A furious and aggressive client is put in restraints and told that the restraints will be removed once the she regains control. At which time is removal of the restraints by the nurse appropriate? When medication that has been administered has taken effect When the client apologizes and tells the nurse that it will never happen again When the nurse explores with the client the reasons for the angry and aggressive behavior7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 82/116 When no acts of aggression are observed in the hour after the release of two extremity restraints Correct! Correct! Rationale: The best indicator that the behavior is under control is that the client exhibits no sign of anger or aggression after being partially released from the restraints. After medication that has been administered has taken effect, the nurse explores with the client the reasons for the angry and aggressive behavior. An apology from the client is not an indication that it is safe to remove the restraints. Test-Taking Strategy: Use your knowledge of the subject, legal and ethical issues involving restraints, to answer this question. Also note the relationship between the word “aggressive” in the question and “aggression” in the correct option. Review the issues related to restraints if you had difficulty with this question. Cognitive Ability: Evaluating Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Evaluation Content Area: Mental Health Question 69 1 / 1 pts A nurse is participating in a care planning conference for an older client with a diagnosis of depression. In preparing the plan, the nurse recalls which piece of information? Older clients do not commit suicide. Depression in an older person is never treatable. Depression in an older person will not cause physical manifestations.7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 83/116 Indications of dementia may be present in an older client with depression. Correct! Correct! Rationale: Signs of dementia may be noted in an older client with depression. Often the older client is aware of the changes in mentation, leading to depression. The other options are all inaccurate statements. Test-Taking Strategy: Use the process of elimination and focus on the subject, an older client with depression. Eliminate the options containing the closed-ended words “not” and “never.” Review depression in the older client if you had difficulty with this question. Cognitive Ability: Understanding Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Question 70 1 / 1 pts A resident of a long-term care facility who has Alzheimer disease becomes agitated when a group of children comes to sing and dance at the facility and tries to take one of the children to her room. Which piece of information should the nurse use when approaching the client about this behavior? This resident is a dangerous individual. Individuals with Alzheimer disease are likely to be child molesters. This resident probably had an unfortunate experience while singing and dancing in her own youth.7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 84/116 Individuals with Alzheimer disease have difficulty tolerating excessive stimulation and changes in routine. Correct! Correct! Rationale: Clients with Alzheimer disease, a form of dementia, are likely to be intolerant of excessive stimulation and changes in routine. The remaining options are incorrect statements about clients with Alzheimer disease. Test-Taking Strategy: Use the process of elimination focusing on the subject, the client’s diagnosis, Alzheimer disease. Recalling the pathophysiology associated with this disease and that it is a form of dementia will direct you to the correct option. Review Alzheimer disease if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Question 71 1 / 1 pts A nurse is working to formulate a plan for discharge with an older client who has been hospitalized and the client’s family. Working with the registered nurse in guiding the discussion with the client and family, the nurse understands that most older persons prefer to live in which situation? Alone With their children In long-term care facilities Correct! Correct! Independently but close to their children7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 85/116 Rationale: Most older people prefer to maintain their independence while having the resource of children or family nearby to help in times of need. In general terms, the other options are not as favorably received by older adults, but their reception also depends on the specific client and the specific situation. Test-Taking Strategy: Use knowledge of the subject, developmental stages of the older client, to answer the question. Think about your knowledge of the older client and remember that most want to maintain their independence. Review the developmental characteristics of the older adult if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Fundamental Skills—Developmental Stages Question 72 1 / 1 pts A nurse is collecting data from a client in crisis and assessing the potential for self-harm. Which finding indicates that the client is at high risk for suicide? The client is impulsive. The client is disorganized. The client has a history of suicide attempts. Correct! Correct! The client has an immediate plan for a suicide attempt.7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 86/116 Rationale: Clients at high risk for suicide include those with a history of a dual diagnosis of mental illness and substance abuse, a personal or family history of suicide attempts, depression, alcoholism, and psychotic episodes. Having a plan, however, particularly involving a method that is immediate and available, puts the client at very high risk. The client may have lethality potential if he or she appears impulsive and disorganized, but these two findings are not as immediately alarming as a suicide plan. Test-Taking Strategy: Use the process of elimination. Noting the strategic words “at high risk” should easily direct you to the correct option. Also note the strategic words “immediate plan” in the correct option. Review the risk factors associated with suicide if you had difficulty with this question. Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Question 73 1 / 1 pts A nurse is providing information to a group of nursing staff members about caring for suicidal clients. Which should be provided in the discussion? Correct! Correct! Discussing suicide with a client is not harmful. Those clients who talk about suicide never actually try it. Depressed clients are the only people who commit suicide. When a person makes suicide threats, the only thing the person wants is attention.7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 87/116 Rationale: An open discussion of suicide is not harmful, will not encourage a client to make the decision to commit suicide, and will, in fact, often help prevent it. Such a discussion gives health care personnel the opportunity to assess the likelihood of a suicide attempt by the client and take the necessary precautions to keep the client safe. The remaining options present incorrect information. Test-Taking Strategy: Use the process of elimination and your knowledge of the subject, concepts related to suicide. Eliminate the options that contain the words “never” and “only” because these words are closed-ended. If you had difficulty with this question, review information on the suicidal client. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Mental Health Question 74 1 / 1 pts A 2-year-old child is a suspected victim of child abuse, and the nurse is interviewing the child’s parent. Which statement by the parent indicates the possibility of child abuse? “My child can’t be expected to learn everything at once.” “I can expect my child to talk using some words at this age.” “I expect my child to try doing some things without my help.” “When I tell my child to do something, I don’t expect to have to repeat myself.” Correct! Correct!7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 88/116 Rationale: One characteristic of abusive parents is toohigh expectations. As a result, the child cannot live up to the expectation of the adult parent. Unrealistic expectations result in parental disappointment and frustration; the parent may even believe that the action of the child is intentional or done out of spite and may react in an excessive manner, resulting in severe injury to the child. Therefore the nurse would be concerned about child abuse if a parent were to state, “When I tell my child to do something, I don’t expect to have to repeat myself.” The statements in the other options are not characteristic of a child abuser. Test-Taking Strategy: Use the process of elimination and focus on the subject, a characteristic statement that might be made by a child abuser. Eliminate the comparable or alike options that are statements reflecting appropriate understanding of the growth and development activities of the 2-year-old. Also note that the correct option presents an unrealistic expectation. If you had difficulty with this question, review growth and development and the characteristics associated with child abusers. Cognitive Ability: Analyzing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Question 75 1 / 1 pts A mental health nurse is conducting the initial assessment of a client who weighs 325 pounds. The client confides that she was sexually molested at age 7 and began putting on weight thereafter. The nurse determines that the client’s symptoms are compatible with a somatization disorder and recalls that obesity for this client most likely represents which factor? Satisfaction with self A form of functional coping7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 89/116 Correct! Correct! Protection from the risk of intimacy Long-term lack of compliance with weight programs Rationale: Clients who become obese after a trauma such as the one described in the question may be trying unconsciously to present themselves as unattractive as a means of protecting themselves from the danger of intimacy. The client’s symptoms are not compatible with satisfaction with self or functional coping. There is not enough information in the question to indicate a long-term lack of compliance with weight programs. Test-Taking Strategy: Use your knowledge of the subject, somatization disorders and the effects of sexual abuse, to answer this question. Begin by eliminating the options that contain the words “satisfaction” and “functional.” Next focus on the data in the question and eliminate the option that contains the words “long-term lack of compliance” because the information in the question does not support this fact. Review somatization disorders if you had difficulty with this question. Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Question 76 1 / 1 pts A client with a history of multiple somatic complaints involving several organ systems has no evidence of organic pathologic conditions. It is important for the nurse assisting with planning care for this client to understand that the client is afflicted with which disorder? Paranoia Depression7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 90/116 Schizophrenia Correct! Correct! Somatization disorder Rationale: Somatization disorder is characterized by a long history of multiple problems with no organic cause. This characteristic is not found in clients with the other mental health disorders listed. Test-Taking Strategy: Focus on the data in the question, and note the strategic words “multiple somatic complaints.” Note the relationship of the word “somatic” and “somatization” in the correct option. Review the characteristics of somatization disorder if you had difficulty with this question. Cognitive Ability: Understanding Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Question 77 1 / 1 pts A nurse sees a nursing assistant talking in an unusually loud voice to a client with delirium. Which action should the nurse take? Informing the client that everything is all right Speaking to the nursing assistant immediately, while in the client’s room, to solve the problem Explaining to the nursing assistant that yelling in the client’s room is tolerated only if the client is talking loudly7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 91/116 Determining that the client is safe, calmly asking the nursing assistant to join you outside the room, and informing the nursing assistant of the observation Correct! Correct! Rationale: The nurse must determine that the client is safe and then discuss the matter with the nursing assistant in an area out of the client’s hearing. If the client hears the conversation, the client might become more confused or agitated. Informing the client that everything is all right is inappropriate and a communication block. Speaking to the nursing assistant immediately to solve the problem, while in the client’s room, could add to the client’s confusion and embarrass the nursing assistant. Explaining to the nursing assistant that yelling in the client’s room is tolerated only if the client is talking loudly could also add to the client’s confusion. Test-Taking Strategy: Use your knowledge of Maslow’s Hierarchy of Needs theory and therapeutic communication techniques. Next recall that safety needs are a priority and note that the correct option contains the word “safe.” Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Leadership and Management— Delegating/Prioritizing Question 78 1 / 1 pts A nurse is preparing to provide nursing unit information to a client who does not speak English and is being admitted to the mental health unit. Which action is best for the nurse to take to ensure that the client understands the information? Asking a family member to translate for the client7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 92/116 Correct! Correct! Obtaining a hospital interpreter to communicate with the client Asking a hospitalized client who speaks the same language as the client to translate Providing the client with a pamphlet that explains the nursing unit information in the client’s language Rationale: Obtaining a hospital interpreter to communicate with the client is the best action because it will ensure that the client clearly understands the nursing unit information. Asking a family member to translate is not appropriate because the nurse cannot be sure that the client is receiving the correct information. It is inappropriate to ask a hospitalized client to translate. Again, the nurse cannot be sure that the client is receiving the correct information, plus this action may violate both clients’ rights to privacy and confidentiality. Providing the client with a pamphlet that explains the nursing unit information in the client’s language may be an additional method of providing information but should not be the only method. Test-Taking Strategy: Note the strategic word “best” in the question. Use the process of elimination and eliminate the comparable or alike options that violate the client’s privacy. Next remember that a hospital interpreter will be able to explain information accurately in lay terms. Review communication techniques for a client who speaks a different language if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Cultural Diversity Question 79 0 / 1 pts A client says to the nurse, “I’m going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 93/116 like this! I'm the one who’s dying.” Which response by the nurse would be most therapeutic? Y You Answered ou Answered “Have you shared your feelings with your family?” “Well, it sounds like you’re being pretty pessimistic.” “I think we should talk more about your anger with your family.” “You’re feeling angry that your family continues to hope for you to be cured.” Correct Answer Correct Answer Rationale: Reflection is the therapeutic communication technique in which the client’s feelings are restated to validate what the client is saying. The correct option involves the use of reflection. In asking, “Have you shared your feelings with your family?” the nurse attempts to assess the client’s ability to openly discuss these feelings with family members, but this is not the most therapeutic response of the options provided. In stating “Well, it sounds like you’re being pretty pessimistic,” the nurse makes a judgment and is nontherapeutic. In stating “I think we should talk more about your anger with your family,” the nurse attempts to use focusing, but the attempt is premature. Test-Taking Strategy: Use therapeutic communication techniques to answer the question. Note that the correct option uses reflection and redirects the client’s feelings back to the client for validation. Review the therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Question 80 1 / 1 pts7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 94/116 A nurse is caring for an older adult client who says, “I don't want to talk with you—you’re only a nurse. I’ll wait for my doctor.” Which response by the nurse would be therapeutic? “I’ll leave you now and call your health care provider.” “So you’re saying that you want to talk to your health care provider?” Correct! Correct! “I’m angry with the way you’ve dismissed me. I am your nurse!” “I’m assigned to work with you. Your doctor placed you in my hands.” Rationale: The nurse uses the therapeutic communication technique of reflection to redirect the client’s feelings back for validation and focus on the client’s desire to talk with the health care provider. The correct option involves the use of reflection. The nursing responses in the other options are nontherapeutic. Remember that the nurse places the client’s well-being first and foremost during care. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques and eliminate the comparable or alike options that are nontherapeutic. Note that the correct option involves the use of reflection and redirects the client’s feelings back to the client for validation. Review the therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 95/116 Question 81 1 / 1 pts A client and her newborn infant have undergone human immunodeficiency virus (HIV) testing, and the results for both clients are positive. The news is devastating, and the mother is crying. What is the appropriate nursing action at this time? Describe the stages of and treatments for HIV. Correct! Correct! Listen quietly while the mother talks and cries. Discuss with the mother how she might have gotten HIV. Call an HIV counselor, and make an appointment for the woman. Rationale: This client has just received devastating news and needs to have someone present with her as she begins to cope with it. The nurse needs to sit and actively listen while the mother talks and cries. Calling an HIV counselor may be helpful, but it is not what the client needs at this time. The other options are not appropriate for this stage of coping with the news that both the client and her infant are HIV positive. Test-Taking Strategy: Use the process of elimination. Noting the strategic words “at this time” will assist you in eliminating the incorrect options. Also note that the correct options address the client’s feelings and support the client. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Question 82 1 / 1 pts7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 96/116 A nurse employed in a home care agency is assigned a recently widowed client. When the nurse arrives at the client’s home, the ordinarily immaculate house is in chaos, and the client is disheveled, with the odor of alcohol on his breath. Which statement by the nurse would be therapeutic? “I can see that this isn’t a good time to visit.” Correct! Correct! “You seem to be having a very difficult time.” “Do you think your wife would want you to behave like this?” “What are you doing? How much are you drinking, and how long has this been going on?” Rationale: The therapeutic statement is the one that helps the client explore his situation and express his feelings. The correct option involves the use of reflection and will help the client begin to express his feelings. In stating “I can see this isn’t a good time to visit,” the nurse uses humor to avoid dealing with the client’s behavior. In asking “Do you think your wife would want you to behave like this?” the nurse uses admonishment and tries to shame the client, which is not therapeutic because it belittles the client, will elicit anger, and may cause the client to act out. In asking “What are you doing? How much are you drinking, and how long has this gone on?” the nurse is belittling and uses social communication. Test-Taking Strategy: Use therapeutic communication techniques. The correct option is the only one that addresses the client’s feelings. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 97/116 Question 83 1 / 1 pts A client says to the nurse, “I don’t do anything right. I’m such a loser.” What is the appropriate response? “Everything will get better.” Correct! Correct! “You don’t do anything right?” “You do things right all the time.” “You are not a loser; you are sick.” Rationale: The correct response allows the client to verbalize his feelings. With this response, the nurse can learn more about what the client really means. This option also repeats the client’s statement and allows the lines of communication to stay open. The incorrect options are closed-ended statements that do not encourage the client to explore his feelings further. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. Remember to address the client’s feelings. The correct option is the only one that presents a therapeutic response. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Question 84 1 / 1 pts A client who is experiencing suicidal thoughts says to the nurse, “It just doesn’t seem worth it anymore. Why shouldn’t I just end it7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 98/116 all?” Which statement should the nurse use to gather additional data from the client? “Did you sleep at all last night?” Correct! Correct! “Tell me what you mean by that.” “I know you’ve had a stressful night.” “I’m sure that your family is worried about you.” Rationale: The correct statement allows the client to tell the nurse more about what the current thoughts are, a therapeutic communication technique. The incorrect options are statements that change the subject and block communication. Test-Taking Strategy: Note the strategic words “gather additional data” in the question. Eliminate the options that do not relate directly to assessment of the client. From the remaining options, select the one that involves the use of a therapeutic communication technique. The correct option also relates to the subject of the question and provides the opportunity for the client to express thoughts. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Question 85 1 / 1 pts A nurse working in the emergency department is assisting with data collection on a client and notes many physical injuries. The nurse suspects family-related violence. Which finding is specific to this type of violence?7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 99/116 The client lives in an assisted living facility. The client is financially independent. The client relies on neighbors and friends for transportation to and from appointments. The client lives with one of his or her children and requires extensive assistance with activities of daily living. Correct! Correct! Rationale: Clients who are at risk for family-related violence include those who are dependent on others or who require extensive care with activities of daily living. The client living in an assisted living facility is relatively independent and requires minimal assistance. The client who is financially independent is not considered to be a risk factor for family-related violence. The client who relies on neighbors and friends for transportation is also not considered to be at risk for this type of violence. Test-Taking Strategy: Use knowledge of the subject, family-related violence, to assist you with the process of elimination and analyze each option. Eliminate the options that present a client who is minimally dependent or not dependent on others. From the remaining options, noting the words "extensive assistance" will direct you to the correct option. Review family-related violence if you had difficulty with this question. Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Question 86 1 / 1 pts A client in halo traction says to the nurse, “I can’t get used to this contraption. I can’t see properly on the side, and I keep7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 100/116 misjudging where everything is.” Which response by the nurse is therapeutic? “No one ever gets used to that thing! It’s horrible.” “If I were you, I’d have had the surgery rather than suffer like this.” “Halo traction involves many difficult adjustments. Practice scanning with your eyes after standing up, before you move.” Correct! Correct! “Why do you feel like this when you could have died of a broken neck? This is the way it will be for several months. You need to accept it, don’t you think?”7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 101/116 Rationale: In the correct option, the nurse employs the therapeutic communication technique of reflection, then offers a problem-solving strategy that will help improve the client’s peripheral vision. In stating “No one ever gets used to that thing! It’s horrible,” the nurse provides a social response that contains emotionally charged language and could increase the client’s anxiety. In stating “If I were you, I’d have had the surgery rather than suffer like this,” the nurse undermines the client’s faith in the medical treatment being used by giving advice that is insensitive and unprofessional. In asking “Why do you feel like this when you could have died of a broken neck? This is the way it will be for several months. You need to accept it, don’t you think?” the nurse uses excessive questioning and gives advice, both of which are nontherapeutic. Test-Taking Strategy: Use the process of elimination, seeking the option that represents a therapeutic communication technique. This will direct you to the correct option. This correct option also provides information to the client about the use of the device. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Question 87 1 / 1 pts A client with major depression says to the nurse, “I should have died. I’ve always been a failure.” Which response by the nurse is therapeutic? “I see a lot of positive things in you.” “You still have a great deal to live for.” “Feeling like a failure is part of your illness.”7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 102/116 Correct! Correct! “You’ve been feeling like a failure for some time now?” Rationale: Addressing the feelings expressed by a client is an effective therapeutic communication technique. The correct option is an example of the use of restating. The incorrect options are responses that block communication because they minimize the client’s experience and do not facilitate exploration of the client’s expressed feelings. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. Select the option that directly addresses the client’s feelings and concerns. The correct option is the only one that is stated in the form of a question and is open-ended, thereby encouraging the verbalization of feelings. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Question 88 1 / 1 pts A client who is an alcoholic says to the nurse, “I’m taking milk thistle, so I can drink all I want and never get cirrhosis.” Which statement by the nurse would be therapeutic? “Milk thistle aside, you still need to stop using alcohol. You have a severe drinking problem.” “If milk thistle is so effective, I wonder why the liquor industry isn’t lobbying to put it in alcohol?”7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 103/116 “Milk thistle is used in Europe this way, but research findings are limited, so I’d stop drinking if I had a problem like you do.” “Milk thistle is an herbal extract. It does seem to prevent liver damage and stimulate liver cell regeneration, but it can’t prevent damage to other organs, like your brain.” Correct! Correct! Rationale: The therapeutic nursing statement is the one that educates the client and also debunks the myth, held by the client, that taking milk thistle excuses drinking. In stating, “Milk thistle aside, you still need to stop using alcohol. You have a severe drinking problem,” the nurse denies the benefits of milk thistle (Silybum marianum) by avoidance and preaches to the client about alcoholism, which is nontherapeutic when the client is in denial. In asking, “If milk thistle is so effective, I wonder why the liquor industry isn’t lobbying to put it in alcohol?” the nurse uses sarcasm and absurdity, both of which are nontherapeutic. In stating, “Milk thistle is used in Europe this way, but research findings are limited, so I’d stop drinking if I had a problem like you do,” the nurse uses sarcasm. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. Eliminate the comparable or alike options that indicate that the client has a drinking problem. From the remaining options, note that the correct option educates the client. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Question 89 1 / 1 pts7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 104/116 Which statement made by a client with anorexia nervosa would indicate to the nurse that treatment has been effective? “I no longer have to lose weight.” “I won’t starve myself anymore.” “I’ll eat until I don’t feel hungry.” Correct! Correct! “I went out to lunch today with my cousin.” Rationale: Anorexia nervosa is usually seen in adolescent girls who try to establish identity and control through selfimposed starvation. “I no longer have to lose weight,” “I won’t starve myself anymore,” or “I’ll eat until I don’t feel hungry,” are all verbalizations of the client’s intentions. The statement “I went out to lunch today with my cousin” identifies a concrete action that can be verified. Test-Taking Strategy: Use the process of elimination. Note the strategic words “treatment has been effective.” Select the option that is concrete and can be verified. The correct option is the only concrete action. Review goals of care for the client with anorexia nervosa if you had difficulty with this question. Cognitive Ability: Evaluating Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Evaluation Content Area: Mental Health Question 90 1 / 1 pts A nurse is admitting a client with a diagnosis of anorexia nervosa to the mental health unit. Which characteristic is a hallmark of this disorder?7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 105/116 Social contacts are important. The client is not concerned about food and meal planning. Personal relationships tend to become more superficial and distant. Correct! Correct! The client with anorexia will usually keep his or her weight near normal weight. Rationale: As anorexia nervosa develops, personal relationships tend to become more superficial and distant. Social contacts are avoided because of the fear of being invited to eat and being discovered. The client is preoccupied with food and meal planning (especially for others), his or her own caloric intake throughout the day, and ways to avoid eating. Anorexic persons are likely to become very emaciated and do not maintain a nearnormal body weight. Test-Taking Strategy: Focus on the subject, the characteristics of anorexia nervosa. It is necessary to have knowledge of this disorder to answer correctly. However, recalling that the client with anorexia nervosa avoids personal relationships will direct you to the correct option. Review the characteristics associated with anorexia nervosa if you had difficulty with this question. Cognitive Ability: Understanding Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Question 91 1 / 1 pts A client with the diagnosis of schizophrenia is unable to speak, although nothing is wrong with the organs of communication. The7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 106/116 nurse plans care knowing that this condition is referred to using which terminology? Correct! Correct! Mutism Verbigeration Pressured speech Poverty of speech Rationale: Mutism is absence of verbal speech. The client does not communicate verbally, despite intact physical structural ability to speak. Verbigeration is the purposeless repetition of words or phrases. Pressured speech refers to rapidity of speech, reflecting the client’s racing thoughts. Poverty of speech means diminished amounts of speech or monotonic replies. Test-Taking Strategy: Use the process of elimination. Focusing on the subject, inability to speak, will assist in directing you to the correct option. If you had difficulty with this question, review these altered speech patterns. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Question 92 1 / 1 pts A client tells the nurse, “I am a queen. I’m mean, and I gleam.” The nurse recognizes this as an example of which type of altered speech pattern? Echolalia Tangential speech7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 107/116 Correct! Correct! Clang associations Loosened associations Rationale: Clang associations often take the form of rhyming. Repetition of words or phrases that are similar in sound (rhyming) but in no other way is one of the patterns of altered thought and language noted in schizophrenia. Echolalia is an involuntary parrot-like repetition of words spoken by others. Tangential speech is characterized by a tendency to digress from an original topic of discussion in which a common word connects two unrelated thoughts. Loosened associations are a sign of disordered thought processes in which the person speaks with frequent changes of subject and the content is only obliquely related, if at all, to the subject matter. Test-Taking Strategy: Focus on the data in the question, the client’s statement. Recalling that rhyming occurs in clang associations will direct you to the correct option. Review altered thought and language patterns in schizophrenia if you had difficulty with this question. Cognitive Ability: Understanding Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Question 93 0 / 1 pts A client is severely injured, sustaining a full-thickness circumferential burn to the left leg, after passing out as a result of drinking alcohol and falling into a fire while on a camping trip. In report, the nurse is told that the client has just signed consent for amputation of the limb and that the procedure is scheduled for tomorrow. While caring for the client, the nurse notes that the client is upset and withdrawn. What is the most appropriate nursing action at this time? Correct Answer Correct Answer Reflecting back to the client that he appears upset7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 108/116 Letting the client have some time alone to grieve the impending loss of the limb Reminding the client that the injury was a result of alcohol abuse and referring him for counseling Y You Answered ou Answered Informing the health care provider of the client’s depression and requesting medication to assist the client in coping with the diagnosis Rationale: Reflection statements tend to elicit deeper awareness of feelings. In addition, reflecting to the client that he or she appears upset validates the perception that the client is upset. Letting the client have some time alone to grieve the impending loss of the limb is premature; the client needs support at this time. Informing the health care provider of the client’s depression and requesting medication to assist the client in coping with the diagnosis is also an example of initiating an intervention prematurely. Reminding the client that the injury was a result of alcohol abuse and referring him for counseling is inappropriate and a block to communication. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. Select the option that encourages the client to express his feelings. This will direct you to the correct option. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Question 94 1 / 1 pts7/19/2021 Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83901?module_item_id=1519720 109/116 A male client reports difficulty concentrating, outbursts of anger, and a feeling of being keyed up all the time and states that peer relations are poor. He then tells the nurse that the symptoms started after his best friend was killed in the terrorist attack at the World Trade Center. The nurse suspects that the client is experiencing which disorder? Social phobia Panic disorder Correct! Correct! Posttraumatic stress disorder Obsessive-compulsive disorder Rationale: Posttraumatic stress disorder (PTSD) is a response to an event that would be markedly distressing to almost anyone. Characteristic symptoms include a sustained level of anxiety, difficulty sleeping, irritability, difficulty concentrating, and outbursts of anger. Social phobia and panic disorder are characterized by specific fear of an object or situation. Obsessive-compulsive disorder involves some repetitive thought or behavior. Test-Taking Strategy: Use the process of elimination and your knowledge of the disorders identified in the options.