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PSYCH HESI Questions and Answers (Latest Update 2021) The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem... . What information should the nurse explore in depth with the client based on this screening tool? A. Consumption, liver enzyme, gastrointestinal complaints and bleeding B. Minimize drinking, frequently misses family events, guilt about drinking, amount of daily intake C. Cancer screening results, anger, gastritis, daily alcohol intake D. Efforts to cut down, annoyance with questions, guilt, drinking as an "Eye-opener" -----------D. Efforts to cut down, annoyance with questions, guilt, drinking as an "Eye-opener" 2. A client is admitted to the mental health unit and reports taking extra antianxiety medication because, "I'm so stressed out. I just wanted to go sleep" the nurse should plan one-on- one observation of the client based on which statement? A) What should I do? Nothing seems to help." B) I have been so tired lately and needed to sleep." C) I really think that I don't need to be here." D) I don't want to talk. Nothing matters anymore." -----------D)I don't want to talk. Nothing matters anymore." 3. A male hospital employee is pushed out of the way by a female employee because of an oncoming gurney. The pushed employee becomes very angry and swings at the female employee. Both employees are referred for counseling with the staff psychiatric nurse. Which factor in the pushed employee's history is most related to the reaction that occurred? A) Is worried about losing his job to a woman B) Tortured animals as a child. C) Was physically abused by his mother D) Hates to be touched by anyone -----------C)Was physically abused by his mother 4. The nurse documents the mental status of a female client who has been hospitalized for several days by court order. The client state, "I don't need to be here" and tells the nurse that she believes that the television talks to her. The nurse should document these assessment findings in which section of the mental status exam? A) Level of concentration B) Insight and judgment C) Remote memory D) Mood and affect -----------B)Insight and judgment 5. The nurse on the evening shift receives report that a client is scheduled for electroconvulsive treatment (ECT) in the morning. Which intervention should the nurse implement the evening before the scheduled ECT? A) Hold all bedtime medication. B) Keep the client NPO after midnight. C) Implement elopement precautions. D) Give client an enema at bedtime. -----------B)Keep the client NPO after midnight. 6. A client who is admitted to the mental health unit report shortness of breath and dizziness. The client tells the nurse, "I feel like I'm going to die" which nursing problem should the nurse include in this client's plan of care? A) Mood disturbance B) Moderate anxiety C) Altered thoughts D) Social isolation -----------B)Moderate anxiety 7. A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confuse. The nurse also determines that the client is homeless and slightly suspicious. This client's treatment plan should include what priority problem? A) Self-care deficit. B) Disturbed sensory perception. C) Ineffective community coping. D) Acute confuse. -----------D)Acute confuse. 8. A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone (Risperdal). When the client walks to the nurse's station in a literally contracted position, he states that something has made his body confort into a monster. What action should the nurse take a) Medicate the client with the prescribed antipsychotic thioridazine (mellaril) b) Offer the client a prescribed physical therapy hot pack for muscle spasms. c) Direct client to occupational therapy to distract him from somatic complaints. d)Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia. -----------D.Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia 9. A mental health worker (MHW) is caring for a client with escalating aggressive behavior. Which action by the MHW warrants immediate intervention by the nurse? A) Is attempting to physically restrain the client. B) Tells the client to go to the quiet area of the unit. C) Is using a loud voice to talk to the client. D) Remains at a distance of 4 feet from the client -----------A)Is attempting to physically restrain the client 10. Which nursing actions are likely to help promote the self-esteem of a male client with mental depression. (Select all that apply) A. Ask client what his long term goals are B. Discuss the challenges of his medical condition C. Include the client in determining treatment protocol D. Encourage the client to engage in recreational therapy E. Provide opportunities for the client to discuss his concerns -----------A. Ask client what his long term goals are D. Encourage the client to engage in recreational therapy E. Provide opportunities for the client to discuss his concerns 11. The nurse is preparing medications for a client with bipolar disorder and notices that the antipsychotic medication was discontinued several days ago. Which medication should also be discontinued? a.Lithium (lithotabs ) b.Benztropine (CogenTn) c.Alprazolam (Xanax) d.Magnesium (milk of magnesia) -----------b.Benztropine (Cogentin) 12. The nurse is teaching a client about the initiation of a prescribed abstinence therapy using disulfiram (Antabuse). What information should the client acknowledge understanding? a. Completely abstain from heroin or cocaine use b. Remain alcohol free from 12 hours prior to the first dose c. Attend monthly meetings of alcoholics anonymous d. Admit to others that he is a substance abuse -----------b. Remain alcohol free from 12 hours prior to the Frst dose 13. A male client with schizophrenia is admitted to the mental health unit aµer abruptly stopping his prescripTon for ziprasidone (Geodon) one month ago. Which quesTon is most important for the nurse to ask the client a. Have you lost interest in the things that you used to enjoy? b. Is your ability to think or concentrate decreased? c. How many continuous hours do you sleep at night d.Do you hear sound/voices that others does not hear -----------D. Do you hear sound/voices that others does not hear 14. *During an annual physical by the occupational nurse working in a corporate clinic, a male employee tells the nurse that his high stress job is causing trouble in his personal life. he further explains the he often gets so angry while driving to and from work that he has considered "getting even" with other drivers. how should the nurse respond?* A. Anger is contagious and could result in major confrontation B. Try not to let your anger cause you to act impulsively c. Expressing your anger to a stranger could result in an unsafe situation D. It sound as if there are many situations that make you feel angry. -----------D. It sounds as if there are many situations that make you feel angry 15. A client who has agoraphobia (a fear of crowds) is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care? a.Encourage substitution of positive thoughts for negative ones b.Establish trust by providing a calm, safe environment c.Progressively expose the client to larger crowds d.Encourage deep breathing when anxiety escalates in a crowd -----------B. establish trust by providing a calm, safe environment 16. A female client request that her husband be allowed to stay in the room during the admission assessment . While interviewing the client, the nurse notes a discrepancy between the client's verbal and non-verbal communication. What action should the nurse take? a.Pay close attention and document the nonverbal messages b.Ask the client's husband to interpret the discrepancy c.Ignore the nonverbal behavior and focus on the client's verbal messages. d.Integrate the verbal and nonverbal messages and interpret them as one -----------A. Pay close attention and document the nonverbal messages 17. A male client approaches the nurse with an angry expressions on his face and raises his voice, saying , My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me , I am going to punch him out! The nurse recognizes that the client is using which defense mechanism? A. Denial B. Projection C. rationalization D. splitting -----------B. Projection 18. The nurse orients a female client with depression to her new room on the mental health unit. The client states, "It seems strange that I don't have a TV in my room." Which statement would be best for the nurse to provide? A. You can watch Tv as much as you want outside of your room B. Sometimes clients feel like the TV is sending them messenges C. Its important to be out of your room and talking to others D. Watching TV is a passive activity and we want you to be active -----------C. Its important to be out of your room and talking to others 19. Following surgery, a male client with antisocial personality disorder frequently requests that a specific nurse be assigned to his care and is belligerent when another nurse is assigned. What action should the charge nurse implement? A. Reassure the client that his request will be met whenever possible B. Advise the client that assignments are not based on client request C. Ask the client to explain why he constantly requests the nurse D. Encourge the client to verbalize his feelings about the nurse -----------B. Advise the client that assignments are not based on client request 20. Narcan was administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate (vicodin). Within 15 min the client is alert and oriented. In planning nursing care which intervention has the highest priority at this time? A) Encourage the client to increase fluid intake. B) Obtain the client's serum vicodin level C) observe the client for further narcotic effects D) determine the client's reason for attempting suicide -----------C)observe the client for further narcotic effects 21. A client postpartum depression receives a prescription for sertraline (Zoloft). What information is most important to include in client teaching? A. Avoid processed meats, red wine, swiss cheese B. Contact the healthcare provider immediately if suicidal thoughts occur C. Increase activity level to include a daily exercise routine D. Contact the healthcare provider immediately if muscle stiffness occurs -----------B. Contact the healthcare provider immediately if suicidal thoughts occur 22. A male client with bipolar disorder who began taking lithium carbonate Five days ago is complaining of excessive thirst, and the nurse Finds him attempting to drink water from the bathroom sink faucet. Which intervention should the nurse implement? A. Report the clients serum lithium level to the healthcare provider B. Encourage the client to suck on hard candy to relieve the symptoms C. No action is needed since polydipsia is a common side effect D. Tell the client that drinking from the faucet is not allowed -----------a. Report the client's serum lithium level to the healthcare provider 23. When preparing to administer a prescribed medication to a homeless male at a community psychiatric clinic, the client tells the nurse that he usually takes a different dosage. What action should the nurse take? A. Tell him to take the medication then verify the dosage at the next healthcare team meeting B. Withhold the medication until the dosage can be confirmed C. Inform him that he may refuse the medication and document whether or not he takes it. D. Explain to the client that the dosage has been changed -----------B. Withhold the medication until the dosage can be confirmed 24. The nurse complete an assessment of a client who is experiencing intimate partner violence (IPV) which finding of the injuries should the nurse include in the documentation? A) The client's significant other's statement B)Photographs C) General description D) A summary of the client's feelings -----------B)Photographs 25. The nurse is planning client teaching for a 35 year old client with early alcoholic cirrhosis. Which self-care measure should the nurse emphasize for the client's recovery? A) Support group meetings B) Vit B and multivitamin supplement C) Diet with adequate calories and protein D) Alcohol abstinence -----------D)Alcohol abstinence 26. A client who is being treated with lithium carbonate for bipolar develops diarrhea, vomiting, and drowsiness. What action should the nurse take? A. Notify the healthcare provider immediately and prepare for administration of an antidote B. Hold the medication and refuse to administer additional amounts of the drug C. Record the symptoms as normal side effects and continue administration of the prescribed dosage D. Notify the healthcare provider of the symptoms prior to the next administration of the drug -----------Correct Answer(s): (D) Early side effects of lithium carbonate (occurring with serum lithium levels below 2.0 mEq per liter) generally follow a progressive pattern beginning with diarrhea, vomiting, drowsiness, and muscular weakness. At higher levels, ataxia, tinnitus, blurred vision, and large dilute urine output may occur. (B) is the best choice. Although these are expected symptoms, the healthcare provider should be notified prior to the next administration of the drug. (A, C, and D) would not reflect good nursing judgment. 27. A client with depression remains in bed most of the day, declines activities and refused to eat. Which nursing problem has the greatest priority for this client? A. Loss of interest in diversional activity B. Social isolation C. Refusal to address nutritional needs D. Low self-esteem -----------C. Refusal to address nutritional needs 28. A female client engages in repeated checks of door and window locks. Behavior that prevents her form arriving on time and interferes with her ability to function effectively. What action should the nurse take? A. Ask the client why she checks the locks B. Discuss checking the time frequently C. Determine the type and size of the locks D. Plan a list of activities to be carried out daily -----------D. Plan a list of activities to be carried out daily 29. A client who is admitted with a closed head injury after a fall has a block alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the nurse identify as the priority? A. Place in a side-lying position with head of the bed elevated B. Administer disulfram (Antabuse) immediately C. Give lorazepam (Ativan) PRN for signs of withdrawal D. Provide thiamine and folate supplements as prescribed -----------A. Place in a side-lying position with head of the bed elevated 30. The nurse leading a group sessions of adolescent clients gives the members a handout about anger management. One of the male clients is fidgety, interrupts peers when they try to talk and talks about his pets at home. What nursing action is best for the nurse to take? A. Give the client permission to leave and return in 10 minutes B. Explore the clients' feelings about his pets and home life C. Encourage his peers to help involve him in the activity D. Redirect him by encouraging him to read from the handout -----------D. Redirect him by encouraging him to read from the handout 31. The nurse is preparing medications for a client with bipolar disorder and notices that the antipsychotic medication was discounted several days ago. Which medication should also be discountinued? A. Alprozolam (Xanax) B. Benztropine (Cogentin) C. Magnesium (Milk of Magnesia) D. Lithium (Lithotabs) -----------B. Benztropine (Cogentin) 32. The nurse is completing the admission assessment of and underweight adolescent whois admitted to a psychiatric unit with a diagnosis of depression. Which finding requires notification to the healthcare provider?A)Potassium level 2.9 mEq/dl B) BP of 110/70 mm/hg C) WBC of 10,000 mm3 D) Body mass index of 21 -----------A)Potassium level 2.9 mEq/dl 33. A middle aged adult with major depressive disorder suffers from pyschomotor retardation, hypersommia, and amotivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning? A. Encourage the client to exercise B. Suggest that the client develop a list of pleasurable activities C. Provide education on methods to enhance sleep D. Teach the client to develop a plan structured activities -----------D. Teach the client to develop a plan structured activities 34. A male client with a long history of alcohol dependency arrives in the Emergency Department describing the feeling of bugs crawling on his body. His blood pressure is 170/102, pulse rate is 110 beats/minute, and his blood alcohol level (BAL) is 0 mg/dL. Which prescription should the nurse administer? A. Haloperidol (Haldol) B. Thiamine (Vitamine B1) C. Lorazepam (Ativan) D. Diphenyhydramine (Benadryl) -----------C. Lorazepam (Ativan) 35. A female client reports feeling hopeless and is unable to stop crying. She explains that she is worried about losing her job. Since the client's husband recently lost his job she feels her employment is essential to the family's survival. To evaluate the effectiveness of cognitive- behavioral techniques, which client outcome should the nurse include in the plan of care? A. Relates insight into problematic relationships B. Demonstrates a healthy relationship with husband C. Describes how the family can resolve problems D. Changes thought patterns related to problem solving. -----------D. Changes thought patterns related to problem solving 36. A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. What intervention is best for the nurse to implement? A. Avoid recognizing the behavior B. Isolate the client from other clients C. Administer a PRN sedative D. Escort the client to his room-- -----------D. Escort the client to his room. *Echolalia*- meaningless repetition of another person's spoken words as a symptom of psychiatric disorder 37. A young adult male is hospitalized due to depression and an attempted suicide attempt. The client reports that the he lost job and was angry with his employer for firing him when he took an overdose of pain medications. Which behavior best indicates to the nurse that his condition is improving? A. Initiates interactions with other clients B. Describes verbally when is angry C.Participates in a job search with a social worker D. Denies plans to harm himself or others -----------A. Initiates interactions with other clients 38. A male client comes to the emergency center he has an erection that will no resolve the client reports that he is taking trazodone (desyrel) for insomnia which information is most important for the nurse to ask this client? A) Have you taken any medication for erectile dysfunction?" B) Are you having any other sexual dysfunctions or problems?" C) When was the last time you drank an alcoholic beverage?" D) Do you have a history of angina or high BP?" -----------A)Have you taken any medication for erectile dysfunction?" 39. Following involvment in a motor vehicle collision, a middle-aged adult client is admitted to the hospital with multiple facial fractures. The client's blood alcohol level is high on admission. Which PRN prescription should be administered if the client begins to exhibit signs and symptopms of delirium tremens (DTs)? A. Hydromorphone (Dilaudid) 2 mg IM B. Procholorperazine (Compazine) 5 mg IM C. Chlorpromazine (Thorazine) 50 mg IM D. Lorazepam (Ativan) 2 mg IM -----------D. Lorazepam (Ativan) 2 mg IM 40. A female client, who is wearing dirty clothes and has a foul body odor, comes to the clinic reporting feeling scared because she is being stalked. What action is most important for the nurse to take? A. Assure client that the healthcare provider will see her today B. Recommend that the client talk with a social worker C. Ask the client to describe why she is being stalked D. Offer the client a safe place to relax before interviewing her -----------D. Offer the client a safe place to relax before interviewing her 41. A male veteran who recently returned from a war zone has post traumatic stress disorder (PTSD) and is admitted to the psychiatric ward because of admitted suicicdal ideations. On admission, the client's family informed the healthcare provider that therapy sessions did not seem to be helping. Select only one intervention that has the highest priority A. administer paroxetine 40 mg as prescribed B. develop a list of therapy programs C. remove all shaving equipment D. determine if the client has a sucide plan -----------C. remove all shaving equipment 42. A middle aged female client with no previous psychiatric history is seen in the mental health clinic because her family describes her as having paranoid thoughts. On assessment, she tells the nurse, "I want to find out why these people are stalking me!" Which response should the nurse provide? A. It sounds like the experience is frightening for you B. What makes you think people are stalking you? C. I know you are frightened, but no one is stalking you D. Do you think someone is trying to harm you? -----------A. It sounds like the experience is frightening for you 43. A client on the mental health unit is becoming more agitated, shouting at the staff, and pacing in the hallway. When a PRN medication is offered, the client refuses the medication and defiantly sits on the floor in the middle of the unit hallway. What nursing intervention should the nurse implement first? A. Transport of the client to the seclusion room B. Take other clients in the area to the client lounge C. Quietly approach the client with additional staff members D. Administer medication to chemically restrain the client -----------B. Take other clients in the area to the client lounge 44. A client who is known to abuse drugs is admitted to the pyschiatric unit. Which medication should the nurse anticipate administering to a client who is exhibiting benzodiazepine withdrawl symptoms? A. Diphenhydramine (Benadryl) B. Perphenazine (Trilafon) C. Isocarboxazid (marplan) D. Chlordiazepoxide (Librium) -----------D. Chlordiazepoxide (Librium) for withdrawal only 45. The nurse accepts a transfer to the mental health unit and understands that the client is distractible and exhibiting a decreased ability to concentrate. The nurse has only 15 minutes to talk with the client. To develop a treatment plan for this client, which assessment is most important for the nurse to obtain? A) Motivation for treatment B) History of substance use C) Medication compliance D) Mental status examination -----------D)Mental status examination 46. A male adult is admitted because of an acetaminophen (Tylenol) overdose. After transfer to mental health unit the client is told he has liver damage. Which information is most important for the nurse to include in the client's a discharge plan? A) Eat a high carbohydrate, low fat, low protein diet. B) Do not take any over the counter medication. C) Call the crisis hot line if feeling lonely. D) Avoid exposure to large crowds. -----------B)Do not take any over the counter medication. 47. A male adolescent was admitted to the unit two days ago for depression. When the mental health nurse tries to interview the client to establish rapport, he becomes very irritated and sarcastic. Which action is best for the nurse to take? A) Report the behavior to the next shift. B) Offer to play a game of cards with the client. C) Document the behavior in the chart. D) Plan to talk with the client the next day. -----------B)Offer to play a game of cards with the client. 48. After receiving treatment for anorexia, a student asks the school nurse for permission to work in the school cafeterias part of the school's work study program. What action should the nurse take? A) Refer the student to a psychiatrist for further discussion. B)Recommend assignment to the receptionist's office. C) Suggest that the student work in the athletic department. D) Determine the parents' opinion of the work assignment. -----------B)Recommend assignment to the receptionist's office. 49. A female client on a psychiatric unit is sweating profusely while she vigorously does push ups and then runs the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbance, the client shouts, "I am the boss here. I do what I want." Which nursing problem best supports these observations? A. Deficient diversional activity r/t excess energy level B. Disturbed personal identity r/t grandiosity C. Risk for activity intolerance r/t hyperactivity D. Risk for other related violence r/t disruptive behavior -----------D. Risk for other related violence r/t disruptive behavior 50. While sitting in the day-room of the mental health unit, a male adolescent avoids eye contact, looks at the floor, and talks softy when interacting with the nurse. The two trade places, and the nurse demonstrates the client's behaviors. What is the main goal of this therapeutic technique? A. Discuss the clients feelings when he responds B. Allow the client to identify the way he interacts C. Initiate a non threatening conversion with the client D. Dialogue about the ineffectiveness of his interactions -----------B. Allow the client to identify the way he interacts 51. A nurse is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plans? (select all that apply) A. purchase a gun to use for protection B. Establish a code with family and friends to signify violence C. plan an escape route to use if the abuse blocks the main exit D. have a bag ready that has extra clothes for self and children E. Take a self defense course that retaliates the abuser with injury -----------B. Establish a code with family and friends to signify violence C. plan an escape route to use if the abuse blocks the main exit D. have a bag ready that has extra clothes for self and children 52. A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care? A. Excessive CNS stimulation will reduced B. Co-dependence behaviors will be decreased C. Client's level of consciousness will increase D. Client will not demonstrate cross-addiction -----------A. Excessive CNS stimulation will reduced 53. The nurse is developing unit policies that will incldue nursing guidelines for maintaining a therapeutic milieu. Which interventions should be included when providing a therapeutic milieu in an inpatient setting? A. Opportunities to contribute to one's treatment plan B. One on one dialogue sessions with the therapist C. Regularly scheduled unit activities for peer interaction D. Home visits to reintegrate into the family -----------C. Regularly scheduled unit activities for peer interaction 54. A high school girl reveals to the school nurse that she has been engaging in self- induced vomiting as a weight control measure. Which initial assessment should the nurse focus on with this adolescent? A. National percentile of weight and height B. Frequency of bingeing and purging behaviors C. Perceptions of family and social relationships D. School grades and extracurricular activities -----------B. Frequency of bingeing and purging behaviors 55. An adolescent male receives a prescription for an antidepressant drug because he is exhibiting a depressed affect. While the client is taking the anitdepressant, which comparison of the client's behavior before and after taking the drug is most important for the nurse to obtain? A. His appetite B. The emotional quality of his attitude C. His level of activity D. The interactions he has with others -----------B. The emotional quality of his attitude 56. A family high school teacher who was a child of alcoholic parents seek counseling at the community health clinic because of depression over a student who was killed by a drunk driver. After several weeks of counseling, which client behavior is the best indicator that the client is coping well with the anxiety related to the students death? A. Signs a safety contract with the nurse agreeing not to hurt herself or others B. Confronts her parents about the hurt she felt as a child of alcoholic parents C. Becomes the faculty sponsor for Students Against Drunk Driving (SADD) D. Describes alternatives to becoming depressed over the student's deaths -----------C. Becomes the faculty sponsor for Students Against Drunk Driving (SADD) 57. While interviewing a client, the nurse takes notes to assist with accurate documentation later. Which statement is most accurate regarding note-taking during an interview? A. The nurse's ability to directly observe the clients nonverbal communication is limited with note taking. B. Taking notes during an interview is a legal obligation of the examining nurse C. The client's comfort level is increased when the nurse breaks eye contact to take notes D. The interview process is enhance with note taking and allows the client to speak at a normal pace -----------A. The nurse's ability to directly observe the clients nonverbal communication is limited with note taking. 58. Which client statement suggest to the nurse that the client is using the defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit? A. I am here because the police thought I was doing something wrong B. At least I hit the wall instead of hitting the psychiatric aide C. I want to be here because I know it is the best psychiatric facility D. Dont believe everything my family tells you, I am not crazy -----------A. I am here because the police thought I was doing something wrong 59. A male client with bipolar disorder tells the nurse that he needs to "make some deals so that he can improve his retirement savings." Based on this information, which client outcome should the nurse include in the plan of care? A. delay business decisions until his mania subsides B. Identify the feelings associated with his behavior C. Seek legal counsel when making business decisions D. Describe why he feeling fearful about his finances -----------A. delay business decisions until his mania subsides 60. A client with schizophrenia explains that she has 20 children and then very seriously points to the nurse and explains that she is one of them. What is the most therapeutic response for the nurse to provide? A) Let's go ask another nurse if this true." B) My name tag shows that I am a nurse here." C) I cannot possibly be one of your children" D) I know that you don't have 9 children" -----------B)My name tag shows that I am a nurse here." 61. The nurse on the day shift receives report about a client with depression who w the weekend. The nurse walks into the client's room in the morning and finds the what intervention is best for the nurse to implement? A) Assist the client to get out bed and involved in an activity B) Monitor the client's appetite and pattern of sleep C) Assess the client's feelings about the hospital stay D) Explain that staff will check on the client every 30 min -----------A)Assist the client to get out bed and involved in an activity. 62. A client who refuse antipsychotic medications disrupts group activities, talks with nonsensical words wanders into client's room. The nurse decides that the client needs constant observation based on which of these assessment findings? A) Wanders into client's rooms B) Refuse antipsychotic medication C) Talks with nonsensical words D) Disrupts group activities. -----------A)Wanders into client's rooms. 63. A teenager who has lost 20 pounds in the last three months is admitted to the hospital with hypotension and tachycardia. The client reports irregular menses and hair loss. Which intervention is most important for the nurse to include to in the clients plan of care? A. Initiate a caloric and nutritional therapy B. Implement behavioral modification therapy C. Evaluate the client for low self esteem D. Record daily weights and graft trend -----------A. Initiate a caloric and nutritional therapy 64. A male client with known auditory hallucinations begins talkingloudly and gesturing wildly while in the unit's day room. What action should the nurse implement first? A. Administer a PRN sedative B. Sit in the chair next to the client C. Escort the client to his room D. Listen to what the client is saying -----------D. Listen to what the client is saying 65. A woman brings her 48 year old husband to the outpatient psychiatric unit and describes his behavior to the admitting nurse. She states that he has been sleepwalking, cannot remember who he is, and exhibits multiple personalities. The nurse knows that these behaviors are often associated with A. post traumatic stress syndrome B. Panic disorder C. dissociative disorder D. Obsessive compulsive disorder -----------C. Dissociative Disorder 66. A male client who recently lost a loved one arrives at the mental health center and tells the nurse he is no longer interested in his usual activities and has not slept for several days. Which nursing problem should the nurse include in this client's plan of care? A. Risk for suicide B. Sleep deprivation C. Situational low self-esteem D. Social Isolation -----------B. Sleep Deprivation 67. A female client with a history of drinking who was admitted 8 hours ago after receiving treatment for minor abrasions occurred from a fall at home. The nurse determines the client's blood alcohol level (BAL) was not analyzed on administration. what action should the nurse take? -----------Ask client about alcohol quantity, frequency, and time of last drink 68. A male client is admitted to the psychiatric inpatient unit with a bandaged flesh wound after attempting to shoot himself. he is recently divorced one year ago, lost his job four months ago, and suffered a break up of his current relationship last week. What is the most likely source of this client's current feelings of depression -----------sense of loss 69. What is the most important goal for a client diagnosed with major depression who has been receiving an antidepressant medication for two weeks -----------not attempt to committ suicide 70. A male adult comes to the mental health clinic and walks back and fourth in front of the office door, but does not enter the office. He then walks around a chair that is in the hallway several times before sitting down in the chair. What action should the nurse take first -----------observe the client in the chair 71. A male client in the mental health unit is guarded and vaguely answers the nurse's questions. He isolates to his room and sometimes opens the door to peek into the hall. Which problem can the nurse anticipate -----------delusions of persecution 72. A male client who is seen in the mental health clinic monthly reports feeling very stressed and nervous and further describes becoming angry increasingly more often during the last month. What action should the nurse take first -----------ask the client to identify problems that have occured during the last month 73. A 25-year-old female client has been particularly restless and the nurse finds her trying to leave the psychiatric unit. She tells the nurse, "Please let me go! I must leave because the secret police are after me." Which response is best for the nurse to make? A) No one is after you, you're safe here. B) You'll feel better after you have rested. C) I know you must feel lonely and frightened. D) Come with me to your room and I will sit with you. -----------(D) is the best response because it offers support without judgment or demands. (A) is arguing with the client's delusion. (B) is offering false reassurance. (C) is a violation of therapeutic communication in that the nurse is telling the client how she feels (frightened and lonely), rather than allowing the client to describe her own feelings. Hallucinating and/or delusional clients are not capable of discussing their feelings, particularly when they perceive a crisis. 74. A male client arrives at the mental health clinic and asks the nurse for more lithium and the antidepressant (Elavil) that he uses to help him sleep. After reviewing his assessment findings with the healthcare provider, a serum creatinine is obtained. What information supports the reason for this laboratory test -----------Lithium is excreted by the kidneys and creatinine is related to kidney functioning 75. When preparing to administer a domestic violence screening tool to a female client, which statement should the nurse provide -----------all clients are screened for domestic abuse because it is common in our society 76. A client with schizophrenia who is taking Haldol begins exhibiting tremors of the extremities. Which intervention should the nurse implement *(think toxicity)* -----------consult with the healthcare provider about reducing the dosage 77. Patient with schizophrenia, drug and alcohol abuse in hospital for hepatitis, contant healthcare provider before giving -----------acetaminophen 78. Antidepressant side effects -----------dry mouth, blurred vision, constipation 79. An woman who started chemotherapy three days ago for cancer of the breast calls the clinic reporting that she is so upset she cannot sleep. The client has several PRN medications available. Which drug should the nurse instruct her to take? -----------Lorazepam (Ativan) 8 mg PO HS 80. A young woman is preparing to be discharged from the psychiatric unit. Which nursing intervention is most important for the nurse to include in this phase of the nurse client relationship -----------explore the client's feelings related to discharge 81. Postpartum depression Sign & Symptoms (3) -----------distrubed sleep, sadness, poor concentration 82. Patient is stealing clothes. What intervention can the nurse implement? -----------encourage client to actively participate in activity 83. Heatlh assessment of history of alcohol dependency WHAT ELSE WOULD BE A CONCERN -----------pancreatitis 84. Patient had a knee surgery post op and diaphoretic and visual hallucinations (what to do first) -----------obtain vital signs 85. Aspiration due to caustic material related to suicide attempt. (nursing diagnosis) -----------ineffective breathing pattern 86. A 38 year old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her food to eat and tells the nurse, "I know you are trying to poison me with that food." Which response would be most appropriate for the nurse to make? -----------"I'll leave your tray here. I am available if you need anything else." 87. During a one-to-one session, the nurse begins to become angry with the client. Which action should the nurse take? -----------Terminate the session before the feelings escalate. 88. A client with paranoia is admitted to the mental health unit and immediately goes to the corner of the room and sits quietly without communicating. In approaching the client, what intervention should the nurse implement first? -----------Explain the nurse's role to the client. 89. History of alcoholism admitted for detoxification; 6 mg of ativan was administered. what additional prescription should the nurse administer immediately? -----------vitamin B1 (thiamine) 90. Schizoprenic client return to clinic 2 weeks after recieving dose of haldol; important info for the nurse to obtain during this visit -----------current vital signs 91. PTSD admitted to psychiatric unit, which intervention is most important for plan of care (think of an ideal environment) -----------provide a quiet room away from the recreational area 92. "I dont know, i just cant think" what activity should the nurse suggest -----------set daily goals in the community meeting 93. Assessing male client with paranoia, which behavior can this client be expected to exhibit -----------is openly hostile towards others for no apparent reason 94. 8 month old with profound mental and physical disabilities. (what to ask the mother) -----------ask mother is she has ever thought about harming herself or her child 95. Bipolar disorder depakote for manic reactions. monitored for seizure -----------observe the client for a reduction in hyperexcitable bahaviors because the drug enhances cerebral inhibitory transmitters 96. Chronically depressed older male client of a long term care facility becomes more reclusive and today refuses to leave room (what intervention should you implement, what should u ask the client?) -----------may i sit for you for a while 97. Wife having affair, sober of 3 years, i believe in god -----------what is troubling you most 98. Smearing feces on the bathroom wall. what intervention should you implement? -----------escort the client out of the bathroom 99. Patient says "i know marijuana is not addicting". what is the nurse's best response? -----------anytime you alter your ability to think clearly you put yourself and others at risk 100. Patient has catatonic schizoprenia, emphysema, DM2, hyperlipidemia. what should the nurse do first? -----------check blood glucose measurement 101. Patient is admitted with borderline personality disorder self inflicted lacerations on abdomen. what should the nurse do? -----------perform the dressing change in a non judgemental manner 102. Male client admitted depression and self mutilation. what should the nurse ask the patient? -----------ask if the client has a plan to harm himself 103. admitted relationship distress with spouse and depressed mood, which diagnostic test. what test should the nurse request? -----------urine drug screen 104. 1.5 lithium admitted for suicidal ideations. what should the nurse advise the patient? -----------instruct client to drink 3 liters of fluid in 24 hours Lithium levels- 0.4-1.0 lithium level over 1.0 toxicity can occur 105. Teen in ER for threatening teacher. what interventions should the nurse implement? -----------discuss methods of clearly communicating screenshot 106. Patient seeing snakes. what medication should the nurse administer -----------administer ativan 107. Patient complains of blindness -----------Conversion disorder 108. College student hears kill, kill. what question should the nurse ask the patient? -----------are you planning to obey the voices 109. A client with bulimia what do you do? (think fluids) -----------assess and report electrolyte imbalance 110. 14 year old eating disorder what do you get them involved in -----------arts and crafts 111. Client 164 cm 36 kg after syncope episode at home. what nursing intervention should the nurse implement? *syncope*--defined as a short loss of consciousness and muscle strength, characterized by a fast onset, short duration, and spontaneous recovery. -----------insert peripheral IV fluid resuscitation 112. Attempted suicide by slashing wrists. what should the nurse do first? -----------check the client level of consciousness 113. How do you take antabuse -----------each morning beginning 48 hours after your last drink of alcohol. this should be past 12 hours 114. A male client is admitted to the er; overdose of benzodiazepine. what should the nurse administer? -----------administer narcan 115. Cancer patient who becomes dependent. -----------expected, as the client to a quiet area of the unit 116. Patient hears voice and becomes agitated. what should the nurse do? -----------move the client to a more quiet area 117. Patient is suffering from recent suicide attempt, wife filed for divorce, loss job. what intervention should the nurse implement? -----------encourage activities that will allow him to take control over his environment 118. Female low cut blouse, red lipstick. What should the nurse do? -----------assist the client back to her room and help her select appropriate clothing 119. Mother yells "dont touch him" as the nurse gives child -----------projects the feelings onto the nurse 120. Female depressed patient begins to talk and exhibit energy. what should the nurse do? -----------continuously observe her actions 121. Male employee says im gonna shoot a coworker. what is the first thing the nurse should do? -----------find out if he has a weapon 122. Client sitting in corner of day room during admission assessment, what nursing action -----------ask client simple questions 123. Two days after last drink, shouts at wife and kids, what nursing intervention has the highest priority (think nursing diagnosis) -----------risk for injury (DT) 124. Nurse documents that a male client with schizophrenia is delusional, what statement made by the client would be an example? Why? -----------nurse at night is trying to poison me with pills (false beliefs of unfounded evidence) 125. Female brought to ER for rape by date -----------my date raped me tonight (exact words from client) 126. Male client on atypical antipsychotic drug olanzapine (zyprexa) (possible side effects?) -----------adverse reaction is weight gain 127. Sometimes my thoughts go so fast, is it time to eat. What kind of thinking is the patient exhibiting? -----------exhibits tangential thinking 128. An adolescent male receives a prescription for an antidepressant drug because he is exhibiting a depressed affect. While the client is taking the antidepressant, which comparison of the client’s behavior before and after taking the drug is most important for the nurse to obtain? a. His appetite b. The emotional attitude** c. His level of activity d. The interaction he has with others ■ The most important assessment is related to mood or the emotional quality of his attitude (B), so the nurse should assess for the presence of depressed mood and suicidal ideation. (A, C, D) can be impacted by antidepressant therapy, but a depressed mood is the cardinal symptom of depression, which should be assessed on a regular basis. 129. The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. Which information should the nurse explore in depth with the client based on this screening tool? a. Consumption, liver enzyme, GI complaints, and bleeding b. Minimizes drinking, frequently misses family events, guilt about drinking, amount of daily intake c. Cancer screening results, age, gastritis, daily alcohol intake d. Efforts to cut down, annoyance with questions, guilt, drinking as an “eye-opener” ■ Cutting down, annoyance, guilty, and eye-opener drinking are represented with the acronym of CAGE. Based on the four CAGE questions (have you ever felt you should cut down on your drinking? Have people annoyed you by criticizing your drinking? Have you ever felt bad or guilty about your drinking? Have you ever had an eye-opener first thing in the morning because of your hangover, or just to get the day started?), the nurse should further explore the client’s behaviors related to his drinking history. (A,B,C) are not included in the CAGE questionnaire. 130. A young adult male is hospitalized due to depression and an attempt suicide attempt. The client reports that he lost his job and was angry with the employer for firing him when he took an overdose of pain medications. Which behavior best indicated to the nurse that his condition is improving? a. Initiates interaction with other clients. b. Describes verbally when he is angry c. Participates in a job search with a social worker d. Denies plans to harm himself or others. ■ The best indicator of improvement in a client with depression is initiated interaction with others (A) because such behavior indicates that the client is less withdrawn and more self-directed. Expressing anger verbally (B), rather than acting out the anger in a suicide attempt, is a goal of therapy, but how the client expresses his anger may at first need to be tempered. Working with the social worker in a job search (C), ay or may not be indication of improvement. The client may be telling the staff what they want to hear when he denies plans to harm himself or others (D). 140. A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. What intervention is best for the nurse to implement? a. Avoid recognizing the behavior b. Isolate the client from other clients c. Administer a PRN sedative d. Escort the client to his room ■ Echolalia, constantly repeating what others are saying, can become disruptive in a community environment, so the nurse should direct the client to a private space, such as his room (D). (A) does not meet the other client’s needs. (B) may seem punitive. Other interventions should be implemented before resorting to the use of a chemical restraint (C). 141. A female client engages in repeated checks of door and window locks, behavior that prevents her from arriving on time and interferes with her ability to function effectively. What action should the nurse take? a. Discuss checking the time frequently b. Ask the client why she checks the locks c. Plan a list of activities to be carried out daily. d. Determine the type and size of locks. ■ (C) helps the client to gain recognition of and insight into the anxiety and assists her to learn new adaptive coping behaviors. (A) does not resolve the anxiety underlying the repetitious behavior. The client uses the behavior to cope with anxiety; she does not understand it and cannot control it (B). Although the focus of the activity is the lock the underlying anxiety is the problem (D). 142. The nurse is teaching a client about the initiation of a prescribed abstinence therapy using disulfiram (Antabuse). What information should the client acknowledge understanding? a. Completely abstain from heroin or cocaine use b. Attend monthly meetings of alcoholics anonymous c. Remain alcohol free for 12 hours prior to the first dose d. Admit to others that he is a substance abuser ■ The client must be alcohol free for 12 hours before the beginning of Antabuse therapy to avoid the precipitation of a disulfiram reaction, and aversive effect. Antabuse is not indicated for other chemical substance addictions (A). Although monthly meetings at AA (B) and admitting his addiction to others (D) are the first steps in recovery, Antabuse is an aversion therapy that induces physiological reactions when alcohol is ingested, which the client must acknowledge understanding. 143. A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and amotivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning? a. Encourage the client to exercise b. Suggest that the client develop a list of pleasurable activities c. Provide education on methods to enhance sleep d. Teach the client to develop a plan for daily structured activities ■ Development of a structured life-style (D) is vital when a client is having difficulty with psychomotor retardation, hypersomnia, and amotivation. (A, B) may be helpful, but the client with depression often lacks the motivation to carry out these activities. Providing instructions about methods to enhance sleep (C) may be helpful, but first the nurse should assist the client in developing a structured life-style, which is likely to assist in enhancing the client’s ability to sleep. 144. A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone (Risperdal). When the client walks to the nurse’s station in a laterally contracted position, he states that something has made his body contort into a monster. What action should the nurse take? a. Medicated the client with the prescribed antipsychotic thioridazine (Mellaril) b. Offer the client a prescribed physical therapy hot pack for muscle spasms c. Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia d. Direct client to occupational therapy to distract him from somatic complaints ■ The client is experiencing a dystonic reaction due to dopamine depletion, one of the physiologic actions of risperidone. This side effect requires immediate management with Cogentin ©, which diminishes excessive cholinergice effects created by the dopamine deficiency. The client is manifesting an extrapyramidal side effect, not a psychotic (A) reaction. Even though somatization (B and D) is a negative component that clients may exhibit, these interventions are not indicated for dystonic side effects of antipsychotic medications. 145. The nurse is preparing medications for a client with bipolar disorder and notices that the antipsychotic medications are discontinued several days ago. Which medication should also be discontinued? a. Alprazolam (Xanax) b. Benztropine (Cogentin) c. Magnesium (Milk of Magnesia) d. Lithium (Lithotabs) ■ Cogentin (B) is given with traditional antipsychotic medications to reduce extrapyramidal side effects and should be discontinued when the antipsychotic medications is discontinued. The client may continue to need (A) for anxiety and (C) for constipation, due to side effects of the other medications the client may be taking. (D) is used to stabilize the client’s mood. 146. The nurse leading a group session of adolescent clients gives the members a handout about anger management. One of the male clients is fidgety, interrupts peers when they try and talk, and talks about his pets at home. What nursing action is best for the nurse to take? a. Give the client permission to leave and return in 10 minutes b. Explore the client’s feelings about his bets and home life c. Encourage this peers to help involve him in the activity d. Redirect him by encourage him to read from the handout ■ The best nursing action is to ask the client to read from the handout (D) and refocus his attention to the activity. (A and B) do not refocus his attention. The nurse, rather than peers, should implement (C). 147. A client who is admitted with a closed head injury after a fall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which interventions during the first 6 hours following admission should the nurse identify as the priority? a. Place in a side-lying position with head of bed elevated b. Administer disulfiram (Antabuse) immediately c. Give lorazepam (Ativan) PRN for signs of withdrawal d. Provide thiamine and folate supplements as prescribed ■ Maintaining the client’s airway is the priority for a client who is intoxicated and obtunded, so placing the client in a side-lying position with the head elevated helps prevent aspiration (A). (B) is contraindicated for the client who is nor alcohol-free for 12 hours. (C) is contraindicated for the client who is difficult to arouse. While (D) is indicated in the prevention of Wernicke’s encephalopathy for client’s with chronic alcohol use, the highest priority for the client is maintenance of the airway. [Show More]

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