HESI MENTAL HEALTH REVIEWS QUESTIONS and ANSWERS (FINAL EDITION)

Document Content and Description Below

HESI RN MENTAL HEALTH Q&A 1. While caring for an older client, the nurse observes multiple bruises over the client’s legs, arms, back, and gluteal areas. When the client contact, the nurse suspec... ts elder abuse. What action should the nurse indicate? ➢ Measure and document size, shape and color of the bruised areas. 2. A client who is homeless is diagnosed with schizophrenia and admitted on an involuntary basis to e mental health hospital 4 days ago. The client stopped taking prescribed antipsychotic drugs approximately one month ago. Since hospitalization the client continues to have poor judgment and refuses all medications. What action should the nurse take? ➢ Administer a long acting antipsychotic medication so that the client can be discharged to a shelter. ? 3. After receiving treatment for anorexia, a student asks the school nurse for permission to work in the school cafeteria as part of the school’s wok study program. What action should the nurse take? ➢ Recommend assignment to the receptionist’s office. 4. A male client comes to the emergency center because he has an erection that will not resolve. The client reports that he is taking trazodone (desyrel) for insomnia. Which information is most important for the nurse to ask this client? ➢ Have you taken any medication for erectile dysfunction? 5. On admission to the mental health unit, a client diagnosed with schizophrenia tells the nurse that he is the son of God. Based on this statement, which intervention should the nurse include in this client’s plan of care? ➢ Confront his delusion as not consistent with reality. 6. The nurse on the day shift receives report about a client with depression who was in bed most of the weekend. The nurse walks into the client’s room in the morning and finds the client in bed. What intervention I best for the nurse to implement? ➢ Assist the client to get out of bed and involved in an activity. 7. Which client information indicates the need for the nurse to use the CAGE questionnaire during the admission interview? ➢ Describes self as a social drinker who drinks alcoholic beverages daily. 8. A female client admitted to the mental health unit stats to shout and scream at the nurse. What is he best approach for the nurse to take? ➢ Stay quietly with the client. 9. A woman is brought to the psychiatric clinic by her husband. He reports that his wife is reluctant to leave home because of what she describes as a fear of open places and crows. Which nursing problems applies to the client’s behavior? ➢ Anxiety related to real or perceived threat to physical integrity. 10. A client is receiving benztropine mesylate (Cogentin) for drug-induced extrapyramidal syndrome (EPS). Which finding indicates that the RN should further evaluate the client? ➢ Presence of a dry mouth. 11. A male client in the mental health unit is guarded and vaguely answers the nurse’s questions. He isolates in his room and sometimes opens the door to peek into the hall. Which problem can the RN anticipate? ➢ Delusions of persecution. 12. 10. A female client engages in repeated checks of door and window locks, behavior that presents her from arriving on time and interferes with her ability to function effectively. What action should the nurse take? ➢ Plan a list of activities to be carried out daily. 13. A female client with obsessive compulsive personality disorder is admitted to the hospital for a cardiac catheterization. The afternoon before the procedure, the client begins to keep detailed notes of the nursing care she is receiving, and reports her findings to the RN at bedtime. What action should the nurse implement? ➢ Encourage the client to express her feelings regarding the upcoming procedure. 14. During admission to the psychiatric unit, a female client is extremely anxious and states that she is worried about the sun coming up the next day. What intervention is most important for the RN to implement during the admission process? Remain calm and use a matter- of-fact approach. 15. A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The RN also determines that the client is homeless and is exhibiting suspiciousness. The client’s plan of care should include what priority problem? ➢ Acute confusion 16. The occupational health nurse is working with a female employee who was just notified that her child was involved in a MVA and taken to the hospital. The employee states, “I can’t believe this. What should I do?” Which response is best for the RN to provide in this crisis? ➢ Call for transportation to the hospital. 17. A male client tells the RN that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. What is the priority nursing problem for admission to the psychiatric unit? ➢ Ineffective sexual patterns. 18. The RN is providing care for a client diagnosed with borderline personality disorder who has self- inflicted lacerations on the abdomen. Which approach should the RN use when changing this client’s dressing? ➢ Perform the dressing change in a non-judgmental manner. 19. While sitting in the day room of the mental health unit, a male adolescent avoids eye contact, looks at the floor, and talks softly when interacting verbally with the RN. The two trade places, and the RN demonstrates the client’s behaviors. What is the main goal of this therapeutic technique? ➢ Allow the client to identify the way he interacts. 20. An antidepressant medication is prescribed for a client who reports sleeping only 4 hours in the past 2 days and weight loss of 9 lbs within the last month. Which client goal is most important to achieve within the first three days of treatment? ➢ Sleep at least 6 hours a night. 21. When preparing to administer to domestic violence screening tool to a female client, which statement should the RN provide? ➢ All clients are screened for domestic abuse because it is common in our society. 22. A young adult female visits the mental health clinic complaining of diarrhea, headache, and muscle aches. She is afebrile, denies chills, and all laboratory findings are within normal limits. During the physical assessment, the client tells the RN that her sister thinks she is neurotic and calls her a hypochondriac. Which response is best for the RN to provide? ➢ Besides your sister’s comments, what in your life is troubling you? 23. The RN is leading a group on the inpatient psychiatric unit. Which approach should the RN use during the working phase of group development? ➢ Helping clients identify areas of problem in their lives. 24. A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. What intervention is best for the RN to implement? ➢ Escort the client to his room. 25. A client is admitted for bipolar disorder and alcohol withdrawal, depressive phase. Based on which assessment finding will the RN withhold the clonidine (Catapres) prescription? ➢ Blood pressure readings of 90/62 mmHg to 92/58 mmHg. Withhold if hypotension occurs 26. The RN on the evening shift receives report that a client is scheduled for electroconvulsive treatment (ECT) in the morning. Which intervention should the Rn implement the evening before the scheduled ECT? ➢ Keep the client NPO after mid-night. To prevent aspiration 27. A client with Bulimia and depression who is taking phenelzine (Nardil) 90 mg daily is admitted to an acute care hospital for uncontrolled hypertension. What dietary choices should the RN instruct the client to avoid? ➢ Peperoni pizza. Bc phenelzine (Nardil ) is monoamine oxidase inhibitor (MAOI) 28. A mental health worker is caring for a client with escalating aggressive behavior. Which action by the mental health worker warrants immediate intervention by the RN? ➢ Is attempting the physically restrain the patient. 29. A client who recently experienced the death of a significant other arrives at the mental health center. The client reports loss of interest in usual activities, expresses a wish to be with the decreased significant other, has been eating very little, and has not slept in several days. Which client statement is most important for the RN to explore at this time? ➢ Not sleeping for several days. 30. A middle aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and motivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning? ➢ Teach the client to develop a plan for daily structured activities. 31. When developing a plan of care for a client admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing problem has the highest priority? ➢ Ineffective breathing pattern. 32. 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? ➢ Risk for other related violence related to disruptive behavior. 33. A RN is preparing the physical environment to interview a new client for admission to the mental health unit. Which environmental setting facilitates the best outcome of the interview? ➢ Reduce the noise level in the room by turning off the television and radio. 34. A female client on a psychiatric unit is sweating profusely while she vigorously does pushups and then runs the length of the corridor several times before crashing in to the furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbances, the client shouts," I am the boss here. I do what I want." Which nursing problem best supports these observations ➢ Risk for other related violence related to disruptive behavior. 35. An older homeless client visits the psychiatric clinic to obtain a prescription renewal for alprazolam (Xanax). During the health assessment, the client complains of chest pain. Which action should the RN take first? ➢ Determine if Xanax was taken recently. 36. The mother of an 8-month-old infant with profound mental and physical disabilities tells he RN how depressed she is because she realized that her child will never achieve normal growth and development milestones. How should the RN respond to the mother? ➢ Ask the mother if she has ever thought about harming herself or her child. 37. The RN is performing intake interviews at a psychiatric clinic. A female client with a known history of drug abuse reports that she had a heart attack four years ago. Use of which substance places the client at highest risk for myocardial infarction? ➢ Methamphetamine 38. Several clients with chronic mental illness and multiple substance abuse histories live in a group residential home and attend daycare mental health facility where group and individual therapies are provided. The RN finds the common bathroom at the facility with sputum on the walls, urine in the sink and on the floors, and the toilet stopped up with tissue, paper towels, and feces. What is the priority issue that the RN should address? ➢ Infection control. 39. A client with schizophrenia is admitted to the psychiatric care unit for aggressive behavior, auditory hallucinations, and potential for safe harm. The client has not been taking medications as prescribed and insists that the food has been poisoned and refuses to eat. What intervention should the RN implement? ➢ Provide the client with food in unopened containers. 40. A nurse is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? (select all that apply). ➢ Establish a code with family and friends to signify violence. ➢ Plan an escape route to use if the abuser blocks the main exit. ➢ Have a bag ready that has extra clothes for self and children. 41. The RN is admitting a male client who take lithium carbonate (Eskalith) twice a day. Which information should the RN report to the HCP immediately? ➢ Nausea and vomiting. 42. A male client who is admitted with delirium tremens is dehydrated and experiencing auditory hallucinations. He has a bruised, swollen tongue and is confused. In developing a plan of care, which action should the RN include to ensure the client is physiologically stable? ➢ Monitor vital signs. 43. A RN is teaching a client about initiation of a prescribed abstinence therapy using Disulfiram (Antabuse). What information should the client acknowledge understanding? ➢ Remain alcohol free for 12 hours prior to first dose. 44. The RN is working with a male client at a community mental health center when the client reports hearing voices that tell him to get a knife from the kitchen and hurt himself. What intervention is most important for the RN to implement? ➢ Assign the UAP to remain with the client at all times. 45. A homeless client who reports feeling sad and depressed tells the mental health nurse that in the past 2 days she has only had 4 hours of sleep. Which action is most important for the RN to implement within the first 24 hours after treatment is initiated? ➢ Allow the client to rest and sleep. 46. Which client statement suggests the RN that the client is using a defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit? ➢ I am here because the police thought I was doing something wrong. 47. A male client is admitted to the psychiatric inpatient unit with a bandaged flesh wound after attempting to shoot himself. He was divorced one year ago. Lost his job four months ago, and suffered a breakup of is current relationship last week. What is most likely source of this client’s current feelings of depression? ➢ A sense of loss 48. The RN documents the mental status of a female client who has been hospitalized for several days by court order. The client states”I don’t need to be here,” and tells the RN that she believes that the t.v talks to her. The RN should document these assessment statements in which section of the mental status exam? ➢ Insight and judgement. 49. An older ale client with schizophrenia is found smearing feces n the bathroom walls of the chronic mental health unit where he resides. What action should the RN implement? ➢ Escort the client out of the bathroom. 50. A male client tells the RN that he does not want to take the atypical antipsychotic drug, olanzapine (Zypexa), because of the side effects he experienced when he took the drug for a year. Which experience is most likely related to taking olanzapine? ➢ Weight gain of 75 lbs. 51. A college student who is a victim of a car-jacking presents to the community health center and report increased anxiety. During the interview, what nursing intervention should take the highest priority? ➢ Help the client feel safe to decrease anxiety. 52. The RN completes an assessment of a client who is experiencing intimate partner violence (IPV). Which finding of the injuries should the RN include in the documentation? ➢ Photographs. 53. Following involvement in a MVC, a middle aged adult client is admitted to the hospital with multiple facial fractures. The client’s blood alcohol level is high on admission. Which PRN prescription should be administered if the client begins to exhibit signs and symptoms of delirium tremens (DTs)? ➢ Lorazepam (Ativan) 2 mg IM. 54. A young adult with eroded tooth enamel presents to the clinic with multiple complaints including severe pain in the chest and upper abdomen that occurred when the client induced vomiting after eating a large breakfast. The client also reports severe heartburn in the last week and describes a history of taking laxatives and eating prunes whenever overeating. What client problem should the nurse address first? Upper abdominal pain 55. A young adult female client is admitted to the emergency department after being raped in a shopping center parking lot. The client expresses no suicidal ideation, but expresses feelings of self-blame for not taking precautions when going to her car. According to theorists, such as Maslow and Erikson, this client is struggling with which issue? Self-control 56. The nurse documents that an adult male client who is depressed sleeps until lunch time and refuses to take telephone calls from his family. Which assessment is most accurate for the nurse to include in the nursing notes in the electronic medical record? Social isolation 57. A client with a history of schizophrenia and drug and alcohol abuse is admitted to the hospital for hepatitis. The nurse should contact the healthcare provider before implementing which prescription? ➢ Acetaminophen (Tylenol) 650 mg PRN. 58. Which finding should the nurse identify as uncomplicated alcohol withdrawal for a client with chronic alcohol use? ➢ Restlessness and irritability. 59. Which individual should the nurse consider at highest risk for suicide? ➢ A retired older male whose significant other as passed away 60. A female client diagnosed with bipolar disorder comes to the dayroom on the psychiatric unit wearing a low-cut blouse and short skirt with no undergarments, bright red lipstick, and several colored ribbons in her hair. Which intervention should the nurse implement? ➢ Assist the client to her room and select appropriate clothing. 61. A female client who is a retired school teacher, is admitted for a breast biopsy. After being told that the biopsy was positive for cancer, she becomes dependent and asks her family for help with activities of daily living that she is physically capable of performing. Which interpretation of the client’s behavior by the nurse is likely to be most accurate? ➢ Expected, as the client is attempting to reduce anxiety by regressing to a state of lesser anxiety. 62. A male client tells the nurse that he would like to try disulfiram (Antabuse) to help reduce his alcohol consumption. How should the nurse respond to the client’s statement? ➢ Disulfiram Antabuse should only be used for clients who want to stop all drinking. 63. The charge nurse of the psychiatric unit observes clients in the day area. Which client is exhibiting symptoms of a conversion disorder? ➢ Blindness with no indication of organic pathology. 64. Prior to initiating a treatment regimen with the antidepressant sertraline (Zoloft), it is most important for the nurse to obtain which information? ➢ Current weight 65. A client who was in a motor vehicle collision related to alcohol intoxication is recovering in the hospital following surgery. Which statement by the client’s spouse indicates codependency? ➢ The spouse informs the client of plans to move out of their home if the drinking doesn’t stop. 66. The mental health team working with a homeless client with chronic schizophrenia establishes the treatment goal of, “improvement in avolition prior to discharge.” Which behavior demonstrates achievement of this goal to the nurse? Reports enjoyment from assigned activities Performs activities of daily living 67. A woman who is currently being evaluated for post-traumatic stress syndrome (PTSD) after experiencing raped and a stabbing last year has recurrent nightmares and is manifesting a detached affect. Which intervention has the highest priority when the nurse is performing the screening interview? (select only one intervention.) Ask the client if she has a plan to harm herself 68. The nurse receives an evening shift report for a client who is scheduled for electroconvulsive therapy (ECT) in the morning. Which medication should the nurse withhold this evening? NO ANSWER 69. A client with a history of alcoholism is admitted for detoxification. Based on treatment protocol, the nurse gives the client a dose of lorazepam (Ativan) 6mg. Which additional prescription should the nurse administer immediately? ➢ Vitamin B1 (thiamine). 70. A male client with schizophrenia is admitted to the mental health unit after abruptly stopping his prescription for ziprasidone (Geodon) one month ago. Which question is most important for the nurse to ask the client? - Do you hear sounds or voices that others do not hear? 71. A female client with a history of drinking who was admitted 8 hours ago after receiving treatment for minor abrasions occurred from a fall at home. The nurse determines the client's blood alcohol level (BAL) was not analyzed on administration action should the nurse take -Ask client about alcohol quantity, frequency, and time of last drink 72. What is the most important goal for a client diagnosed with major depression who has been receiving an antidepressant medication for two weeks -No attempt to committee suicide 73. A male adult comes to the mental health clinic and walks back and forth in front of the office door, but does not enter the office. He then walks around a chair that is in the hallway several times before sitting down in the chair. What action should the nurse take first -observe the client in the chair 74. 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 occurred during the last month 75. A 26-year-old female client has been particularly restless and the nurse finds her trying to leave the psychiatric unit. She tells her the nurse," please let me leave because the secret police are after me." Which response is best for the nurse -come with me to your room and I will sit with you 76. 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 Benztropine (Cogentin) 77. 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 78. A female high school teacher who was a child of alcoholic parents seeks counseling at the community health clinic because of depression over a student who was killed by a drunk driver. After several weeks of counseling, which behavior is the best indicator that the client is coping well with the anxiety related to the student's death becomes the faculty sponsor for students against drunk driving (SADD) 79. 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 80. A client with schizophrenia who is taking Haldol begins exhibiting tremors of the extremities. Which intervention should the nurse implement consult with the healthcare provider about reducing the dosage 81. 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 delay business decisions until his mania subsides 82. patient with schizophrenia, drug and alcohol abuse in hospital for hepatitis, contact healthcare provider before giving acetaminophen 83. An adolescent male client is hospitalized after he threatened a teacher at school. He admits feeling angry because his mother tricked him and brought him to the hospital. The client states that when his mother visits, he plans to get his belongings from her, but is not going to talk to her. Which activity is most important for the nurse to complete before the mother arrives? ➢ Methods of clear communication 84. The nurse is developing unit policies that will include nursing guidelines for maintaining a therapeutic milieu. Which interventions should be included when providing a therapeutic milieu in an inpatient setting? ➢ Regularly scheduled unit activities for peer interaction. 85. A young adult male who was recently diagnosed with bipolar disorder takes lithium carbonate daily. He is graduating from high school next month, and he tells the school nurse that wants to live away from home for college. What information is most important for the nurse to provide the client and his family? ➢ Lithium level routinely. 86. A client who has agoraphobia (a fear of crowds) is beginning desensitization with the therapist, and the RN is reinforcing the process. Which intervention has the highest priority for this client’s plan of care? ➢ Establish trust by providing a calm, safe environment. 87. A client on the mental health unit is becoming more agitated, shouting at the staff, and pacing in the hallway. When the PRN medication is offered, the client refuses the medication and defiantly sits on the floor in the middle of the unit hallway. What nursing intervention should the RN implement first? ➢ Take other clients in the area to the client lounge. 88. A client is admitted to the mental health unit and reports taking extra antianxiety medication because, “I’m so stressed out. I just want to go to sleep.” The RN should plan one-on-one observation of the client based on which statement? ➢ “I don’t want to walk. Nothing matters anymore.” 89. A male hospital employee is pushed out the way by a female employee because of an oncoming gurney. The pushed employee becomes very angry and swings at the female employee. Both employees are referred for counseling with the staff psychiatric RN. Which factor in the pushed employee’s history is most related to the reaction that occurred? ➢ Was physically abused by his mother. 90. A high school girl reveals to the high school RN that she has been engaging in self-induced vomiting as weight-control measure. Which initial assessment should the RN focus on with this adolescent? -frequency of binging and purging behaviors 91. Pt is getting oriented to the unit and replies “there are no TVs in the room” What is the nurse’s best respond? ➢ -it is important to be out of your room and talking to others 92. The nurse orients a female client with depression to the new room on the mental health unit. The client states “It seems strange that I don’t have a T.V in my room.” Which statement would be best for the RN to provide? ➢ “You can watch T.V as much as you want outside of your room.” 93.Depression patient suddenly becomes happy and excited emotion ➢ Continuously watch patient 94. An adolescent make receives a prescription for an antidepressant drug because he is exhibiting a depressed affect. While the client is taking the antidepressant, which comparison of the client’s behavior before and after taking the drug is most important for the nurse to obtain? ➢ An emotional quality of his attitude. 95. A female high school teacher who was a child of alcoholic parents seeks counseling at the community health clinic because of depression over a student who was killed by a drunk driver. After several weeks of counseling, which behavior is the best indicator that the client is coping well with the anxiety related to the student's death ➢ becomes the faculty sponsor for students against drunk driving (SADD) 96. A woman who started chemotherapy three days ago for cancer of the breast calls the clinic reporting that she is so upset she cannot sleep. The client has several PRN medications available. Which drug should the nurse instruct her to take? ➢ Lorazepam (Ativan) 8 mg PO HS 97. When a male client is asked about his reason for coming to the mental health clinic he replies, "It all started because I work in a hostile work environment. My boss would not let me go to a religious service, so I went to human resources, and they didn't want to do anything. It has been a really difficult time for me." Which response should the nurse provide? ➢ "Have the feelings associated with these events brought you to the clinic?" 98. [Show More]

Last updated: 2 years ago

Preview 1 out of 10 pages