Download HESI Mental Health RN Questions and Answers from V1-V3 Test Banks and Actual Exams (Latest and more Exams Nursing in PDF only on Docsity!
Banks and Actual Exams (Latest Update 2021) Rated A+
- During admission to the psychiatric unit, a female client is extremely anxious and states that she is worried about the sun coming up the next day. What intervention is most important for the RN to implement during the admission process?
A. Assist the client in developing alternative coping skills. B. Remain calm and use a matter of fact approach. C. Ask the client why she is so anxious D. Administer a PRN sedative to help relieve her anxiety.
- 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?
A. Acute confusion. B. Ineffective community coping C. Disturbed sensory perception. D. Self-care deficit.
- The occupational health nurse is working with a female employee who was just notified that her child was involved in a MVA and taken to the hospital. The employee states, “I can’t believe this. What should I do?” Which response is best for the RN to provide in this crisis?
A. Tell me what you think should happen. B. How serious was the collision? C. What do you think you should do? D. Call for transportation to the hospital.
- A client tells the RN that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. What is the priority nursing problem for admission to the psychiatric unit?
Banks and Actual Exams (Latest Update 2021) Rated A+
A. Ineffective sexual patterns. B. Impaired environmental interpretation. C. Disturbed sensory perception. D. Compromised family coping.
- 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?
A. Provide detailed thorough explanations when cleansing wound. B. Perform the dressing change in a non-judgmental manner. C. Ask in a non-threatening manner why the client cut own abdomen. D. Request another staff member assist with the dressing change.
- 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?
A. Initiate a non-threatening conversation with the client. B. Dialog about the ineffectiveness of his interactions. C. Allow the client to identify the way he interacts. D. Discuss the client’s feelings when he responds.
- 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?
A. Meet scheduled appointment with dietitian. B. Sleep at least 6 hours a night. C. Understands the purpose of the medication regimen. D. Describes the reasons for hospitalization.
- When preparing to administer to domestic violence screening tool to a female client, which statement should the RN provide?
Banks and Actual Exams (Latest Update 2021) Rated A+
A. Blood pressure readings of 90/62 mmHg to 92/58 mmHg. B. Pulse rate of 68-78 BPM. C. Temperature of 99.5-99.7 F. D. Respiration rate of 24 breaths per minute.
- The RN on the evening shift receives report that a client is scheduled for electroconvulsive treatment (ECT) in the morning. Which intervention should the Rn implement the evening before the scheduled ECT?
A. Hold all bedtime medications. B. Keep the client NPO after mid-night. C. Implement elopement precautions. D. Give the client an enema at bedtime.
- A client with Bulimia and depression who is taking phenelzine (Nardil) 90 mg daily is admitted to an acute care hospital for uncontrolled hypertension. What dietary choices should the RN instruct the client to avoid?
A. Pan-seared catfish. B. Peperoni pizza. C. Deep fried shrimp. D. Beef trips with gravy.
- A mental health worker is caring for a client with escalating aggressive behavior. Which action by the mental health worker warrants immediate intervention by the RN?
A. Is attempting the physically restrain the patient. B. Remains at a distance of 4 feet from the client. C. Tells the client to go to the quiet area of the unit. D. Is using a load voice to talk to the client.
Banks and Actual Exams (Latest Update 2021) Rated A+
- A client who recently experienced the death of a significant other arrives at the mental health center. The client reports loss of interest in usual activities, expresses a wish to be with the decreased significant other, has been eating very little, and has not slept in several days. Which client statement is most important for the RN to explore at this time?
A. Not sleeping for several days. B. Wishing to be with spouse. C. Lack of interest in usual activities. D. Eating very little.
- 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?
A. Provide education on methods to enhance sleep. B. Teach the client to develop a plan for daily structured activities. C. Suggest that the client develop a list of pleasurable activities. D. Encourage the client to exercise.
- When developing a plan of care for a client admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing problem has the highest priority?
A. Impaired comfort. B. Risk for injury. C. Ineffective breathing pattern. D. Ineffective coping.
- 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?
Banks and Actual Exams (Latest Update 2021) Rated A+
walls, urine in the sink and on the floors, and the toilet stopped up with tissue, paper towels, and feces. What is the priority issue that the RN should address?
A. Medication non-compliance. B. Number of bathroom facilities. C. Infection control. D. Acting out behaviors.
- 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?
A. Assure the client that all food served in the hospital is safe to eat. B. Tell the client that irrational thinking is a symptom of schizophrenia. C. Obtain an order for a tube feeding for the client. D. Provide the client with food in unopened containers.
- The RN is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? (SOA)
A. Purchase a gun to use for protection. B. Establish a code with family and friends to signify violence. C. Take a self-defense course that retaliates the abuser with injury. D. Have a bag ready that has extra clothes for self and children. E. Plan an escape route to use if the abuser blocks the main exit.
- The RN is admitting a male client who take lithium carbonate (Eskalith) twice a day. Which information should the RN report to the HCP immediately?
A. Short term memory loss. B. Five pound weight gain C. Decreased affect.
Banks and Actual Exams (Latest Update 2021) Rated A+
D. Nausea and vomiting.
- A male client who is admitted with delirium tremens is dehydrated and experiencing auditory hallucinations. He has a bruised, swollen tongue and is confused. In developing a plan of care, which action should the RN include to ensure the client is physiologically stable?
A. Encourage oral fluids. B. Monitor vital signs. C. Keep the room dark. D. Apply ice to his tongue.
- A RN is teaching a client about initiation of a prescribed abstinence therapy using Disulfiram (Antabuse). What information should the client acknowledge understanding?
A. Admit to others that he is a substance abuser. B. Remain alcohol free for 12 hours prior to first dose. C. Attend monthly meetings of alcoholics anonymous. D. Completely sustain from heroin or cocaine use.
- The RN is working with a male client at a community mental health center when the client reports hearing voices that tell him to get a knife from the kitchen and hurt himself. What intervention is most important for the RN to implement?
A. Don’t allow the client to go into the kitchen until the hallucination has subsided. B. Report the behavior to the client’s case workers so that the family can be notified. C. Assign the UAP to remain with the client at all times. D. Document the behavior in the client’s record and notify the HCP.
- 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?
A. Allow the client to rest and sleep. B. Ensure client attend groups addressing coping skills for dealing with depression.
Banks and Actual Exams (Latest Update 2021) Rated A+
A. Explain that the feces belong in the toilet. B. Show the client how to clean the walls. C. Escort the client out of the bathroom. D. Assist the client to clean the walls.
- A male client tells the RN that he does not want to take the atypical antipsychotic drug, olanzapine (Zypexa), because of the side effects he experienced when he took the drug for a year. Which experience is most likely related to taking olanzapine?
A. Weight gain of 75 lbs. B. Thoughts of wanting to hurt himself. C. Frequent days with diarrhea. D. Alerted liver function test.
- 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?
A. Identify support systems in the community that may be helpful. B. Help the client feel safe to decrease anxiety. C. Ask the client to describe coping strategies that were helpful in the past. D. Encourage the client to verbalize anxiety related to event.
- 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?
A. A summary of the client’s feelings. B. Photographs. C. A general description. D. A client’s significant other’s statement.
- 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
Banks and Actual Exams (Latest Update 2021) Rated A+
prescription should be administered if the client begins to exhibit signs and symptoms of delirium tremens (DTs)?
A. Prochlorperazine (Compazine) 5 mg IM. B. Hydromorphone (Dialuadid) 2 mg IM. C. Chlorpromazine (Thorazine) 50 mg IM. D. Lorazepam (Ativan) 2 mg IM.
- Part Three
- 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?
- A female client engages in repeated checks of door and window locks. Behavior that prevents her from arriving on time and interferes with her ability to function e²ectively. What action should the nurse take plan a list of activities to be carried out daily.
- 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 voices.
- 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.
Banks and Actual Exams (Latest Update 2021) Rated A+
- Conversion disorder patient complains of blindness Conversion disorder Disorder characterized by transferring a mental conflict into a physical symptom for which there is no organic cause. Ex: blindness, paralysis, seizures, deafness, and pseudocyesis(false pregnancy).
- Countertransference occurs when a mental health care professional redirects his or her feelings toward a client or becomes emotionally entangled with a client counter transference.
- Part five
- After returning to work after a weekend off the nurse gets report that a depressed client has been in bed all weekend. What should the nurse to first?
- Assist the client out of bed and involve in activity.
- A client with dementia uses the defense mechanism of confabulation. What is the reasoning?
- To decrease anxiety.
- A husband states to the nurse that his wife is not sleeping, buying impulsively, taking last minute trips, and has lost 22 pounds one month. What is an appropriate nursing dx?
HESI MENTAL HEALTH V3 2017 55 QUESTIONS
- Disturbed thought process.
- A nurse is explaining a fire drill routine to a group of clients. A client becomes disruptive and continually interrupts the group. What is the nurse's best response?
- When you interrupt, I cannot explain what to do to the group.
- When performing a MSE on a client which assessment intervention would best assist the nurse?
- Ask the client to interpret the proverb a stitch in time saves nine.
- A client comes in after being in a car accident and is experiencing alcohol withdrawal, magnesium level of 1.1, cardiac dysthrythmias. What would you give first?
- Magnesium.
- A woman is just told of her husband's dx of terminal cancer. What would the nurse offer for the spouse (wife)?
- How would you like to be involved with your husband's care?
- A nurse is to remove staples from an abdominal incision, the client is very anxious. What is the most important intervention?
- Attempt to distract the client with general conversation.
- A man who was stranded on the roof of his house for two days after a natural disaster, months later ...
- Implement anxiety control strategies
- A man dx with bipolar disorder states, "I don't understand, I believe in God and have not done anything to deserve this". What is the nurse's best response?
- You didn't do anything wrong. You have a chemical imbalance in your brain.
- A client becomes upset when the nurse he requests is not assigned to him, what is the nurse's best response?
- Advise the client that nursing assignments are not based on client requests.
Banks and Actual Exams (Latest Update 2021) Rated A+
- A client needs to wash her hands for two hours before able to go on with her morning. She doesn't want to sit on the chairs in the dayroom for fear of getting dirty. What is this mechanism?
- Compulsion.
- A client in group is talking about her prostitution, the nurse asks her if she was abused by her parents. She states "my mother ran my father out when I was young". What defense mechanism was used?
- Repression.
- A woman calls the crisis hotline and says she has a loaded gun and is going to kill herself. To maintain patient confidentiality what would the nurse do?
- Contact the person the client chooses to go to the home and remove the weapon.
- A client with anger management issues uses belt making and bangs the leather heavily. What defense mechanisms is being used?
- Sublimation.
- A bipolar client comes into the clinic and tells the nurse that the next time she sees her sister I'm going to kill her. What should the nurse do?
- Inform the sister.
- What would be the nurse's highest priority for a newly admitted depressed client upon admission?
- The nurse should go through the client's belongings.
- Who is most prone to being abused (elder abuse)?
- Females over 75 living with their families.
- A client in the dayroom had tipped over a table and is escalating and has picked up a chair which he is threatening to throw at another client. What should the nurse do first?
- Go and get more staff assistance.
- A woman who is psychotic is carrying all of her belongings around with her because she is afraid that someone will steal it. What is the best way to establish trust?
- Make brief contact with the client throughout the day.
- In adolescent group discussing a handout on anger management, a client is becoming increasingly interruptive and talking about his home and pets. What is the nurse's most appropriate response?
- Redirect the client to read the handout.
- What is the most important intervention for a client with bulimia?
- Plan scheduled meals.
- A client comes into the ED with DTs. What should the nurse do first?
- Administer Ativan.
- What are the side effects of Resperdal?
- Fever, tachycardia, and sweating.
- A client who is refusing to take his medication is wandering on the unit and going in and out of resident's rooms. What is the priority?
- Wandering in and out of other client's rooms.
- A nurse observes a client in the dayroom talking to himself. What should the nurse do first?
- Ask the client if he’s currently hearing voices?
Banks and Actual Exams (Latest Update 2021) Rated A+
- A woman is being abused by her husband, the abuse is escalating. What would the nurse ask first?
- Do you have a plan in place when you are not safe? (SAFETY!!!)
- A patient has stopped taking Depakote six months ago, what would the nurse assess?
- Mood.
- A nurse visits a community half way house with one bathroom. The nurse notices urine all over the walls of the bathroom. The toilet is clogged with feces and paper towels.
- Infection control.
- A client with Alzheimer's keeps asking for his mother. What is the nurses appropriate response?
- Your mothers not here but you are safe.
- A client is told to come in by friends, clients complaints include losing his job, just got a divorce, single dad with two kids, what would be the best question for nurse to ask?
- What is troubling you the most?
- What are the side effects of Lithium?
- Dehydration, diarrhea, and thirstiness.
- A client with an anxiety disorder is demonstrating signs of panic. Which intervention would be the most appropriate for the nurse to implement
- Decrease environmental stimuli and interactions with other people.
- A client tells the nurse that he is an accomplished writer and that directors of television shows contact him for suggestions on actors and locations. The nurse realizes this client is experiencing the delusion of
- Grandiosity
- A client tells the nurse that his father died after the client thought abut it for a few days. The nurse suspects the client is delusional and is demonstrating:
- A magical thinking
- The nurse overhears a client diagnosed with terminal cancer tell a family member that he will be discharged soon, will return to work, and plans to attend a company event scheduled in a year. The nurse realizes this client is demonstrating the defense mechanism of
- Denial
- A female client diagnosed with depression tells the nurse that her husband wants her to “fix herself up” and put on nice clothes. The client continues by saying that she believes her husband is interested in another woman. What should the nurse respond to the client?
- I can help you shower and get dressed before he comes to visit
- A client diagnosed with schizophrenia has been refusing prescribed oral medication for several days. The client has broken chair and is coming after another client with the broken chair leg, threatening to do physical harm. What should the nurse do first?
- Remove the other client from the room.
Banks and Actual Exams (Latest Update 2021) Rated A+
- The nurse has identified the diagnosis imbalance Nutrition: More than body requirements for a client diagnosed with bulimia. Which intervention would be appropriate for this diagnosis?
- Help client assess situations that precedes binging
- A client tells the nurse that he has a fear of flying on an airplane but needs to attend a work-related meeting in another part of the country and will have to fly to get there. What can the nurse do to assist this client?
- Instruct the client to visualize flying to the meeting destination
- During an assessment, a client from the Hispanic culture refuses to maintain eye contact with the nurse. After the nurse overhears the client say “evil eye” to a family member, the nurse realizes the client is demonstrating characteristics of which cultural-specific syndrome?
- Induced by witchcraft
- 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 voices
- 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
- 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
- a sense of loss
- 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
- 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
- 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
Banks and Actual Exams (Latest Update 2021) Rated A+
consult with the healthcare provider about reducing the dosage
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
one on one session and nurse begins to get angry at patient
terminate session
patient with schizophrenia, drug and alcohol abuse in hospital for hepatitis, contact healthcare provider before giving
acetaminophen
teenaged girl self-induced vomiting
frequency of binging and purging behaviors
antidepressant side effects
dry mouth, blurred vision, constipation
no TV in room tell patient
it is important to be out of your room and talking to others
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
A male adult is admitted because of an acetaminophen (Tylenol) overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client's discharge plan?
do not take any over the counter meds
patient being discharged
discuss feelings of discharge
The nurse documents the mental status of a female client who has been hospitalized for several days by court order, The client states, "I don't need to be here" and tells the nurse that she believes that the television talks to her. The nurse should document these assessment findings in which section of the mental status exam?
insight and judgement
depressed mother and daughter speaks in group
I hear you say you worry about your mother's distress
Banks and Actual Exams (Latest Update 2021) Rated A+
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?
establish trust by providing a calm, safe environment
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?"
ECT therapy non responsive
have you taken erectile dysfunction meds
adolescent teen interrupts group about pets at home
redirect him
client in bed all weekend, depression
get client out of bed and active
postpartum depression Sign & Symptoms (3)
disturbed sleep, sadness, poor concentration
ECT
NPO after midnight
stealing clothes
encourage client to actively participate in activity
health assessment of history of alcohol dependency WHAT ELSE WOULD BE A CONCERN
pancreatitis
knee surgery post op and diaphoretic and visual hallucinations
obtain vital signs
- aspiration due to caustic material related to suicide attempt
- ineffective breathing pattern
- A 38-yea- old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her food to eat and tells the nurse, "I know
