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HESI RN MENTAL HEALTH HESI REVIEW MULTIPLE CHOICE Answers 202 5 A male client with bipolar disorder who began taking lithium carbonate five days ago is complaining of excessive thirst, and the RN finds him attempting to drink water from the bathroom sink faucet. Which intervention should the RN implement? A. Report the client's serum lithium level to the HCP. 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 HCP. A mental health worker is caring for a client with escalating aggressive behavior. Which action by the MHW warrant immediate intervention by the RN? A. Is attempting to physically restrain the patient. 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 patient. A client is admitted to the mental health unit and reports taking extra antianxiety medication because, "I'm so stressed out. I just want to go to sleep." The RN should plan one-on-one observation of the client based on which statement? A. "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 walk. Nothing matters anymore." - ✔D. "I don't want to walk. Nothing matters anymore." 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. Useof which substance places the client at highest risk for myocardial infarction? A. Benzodiazepine B. Alcohol C. Methamphetamine D. Marijuana - ✔C. Methamphetamine
A male client comes to the emergency center because he has an erection that will not resolve. The client reports that he is taking trazodone (Desyrel) for insomnia. Which information is most important for the nurse ask the client? A. When was the last time you drank alcoholic beverage? B. Have you taken any medications for erectile dysfunction? C. Are you having any other sexual dysfunctions or problems? D. Do you have a history of angina or high blood pressure? - ✔B. Have you taken any medications for erectile dysfunction? A female client admitted to the mental health unit starts to shout and scream at the RN. What is the best approach for the RN to take? A. Stay quietly with the patient B. Tell her that she is out of control. C. Distract her by offering her finger foods. D. Ignore the client's acting out behavior. - ✔A. Stay quietly with the patient 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. - ✔C. Ineffective breathing pattern. 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 related to excess energy level. B. Risk for other related violence related to disruptive behavior. C. Risk for activity intolerance related to hyperactivity. D. Disturbed personal identity related to grandiosity. - ✔B. Risk for other related violence related to disruptive behavior.
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. - ✔B. Remain alcohol free for 12 hours prior to first dose. 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 psychiatricunit? A. At least I hit the wall instead of hitting the psychiatric aide. B. I am here because the police thought I was doing something wrong. C. I want to be here because I know it is the best psychiatric facility. D. Don't believe everything my family tells you, I am not crazy. - ✔B. I am here because the police thought I was doing something wrong. 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? A. Insight and judgement. B. Mood and affect. C. Remote memory. D. Level of concentration. - ✔A. Insight and judgement. An older ale client with schizophrenia is found smearing feces on the bathroom walls of the chronic mental health unit where he resides. What action should the RN implement? 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 - ✔C. Escort the client out of the bathroom. 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 takingolanzapine?
A. Weight gain of 75 lbs. B. Thoughts of wanting to hurt himself. C. Frequent days with diarrhea. D. Alerted liver function test. - ✔A. Weight gain of 75 lbs. 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 toexhibit 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. - ✔D. Lorazepam (Ativan) 2 mg IM. The RN is preparing medications for a client with bipolar disorder and notices that the client discontinued antipsychotic medication for several days. Which medication should also be discontinued? a. Lithium. (Lithotabs) b. Benzotropine (Cogentin). c. Alprazolam (Xanax). d. Magnesium (Milk of Magnesia). - ✔b. Benzotropine (Cogentin). The RN on the day shift receive report about a client with depression who was in bed most of the weekend. The RN walks into the client's room in the morning and finds the client in bed. What intervention is best for the RN to implement? A. Monitor the client's appetite and pattern of sleep. B. Assess the client's feelings about the hospital stay. C. Assist the client to get out of bed and involved in an activity. D. Explain that staff will check on the client every 30 minutes. - ✔C. Assist the client to get out of bed and involved in an activity. Male who was found sitting in the middle of a busy street is brought to the emergency department. Confused and has difficulty answering questions. After ruling out a physiological etiology for the client's behavior. When admitting the client to the unit, which action is most important for the nurse to take? A. Ask the client about his recent substance use B. Perform a mental status exam
C. Verify the client's report by determining if there is physical evidence of abuse D. Assist the client in developing an emergency safety plan - ✔C. Verify the client's report by determining if there is physical evidence of abuse A client with schizophrenia explains that she has 20 children and then very seriously points to the RN and explains that she is one of them. What is the most therapeutic response for the RN to provide? A. "Let's go ask another RN is this is true." B. "My name tag shows that I am a RN here." C. "I can't possibly be one if your children." D. "I know that you don't have 20 children." - ✔B. "My name tag shows that I am a RN here." A young female client is admitted to the emergency room because she was raped that evening by her date. How should the nurse record the client's chief complaint in the medical record? a.) Client reported that she had sexual relations against her will. b.) Client claims that she was forced to participate in sexual intercourse. c.) Client has been sexually assaulted. d.) Client states, "my date raped me tonight." - ✔d.) Client states, "my date raped me tonight." A female client with obsessive compulsive disorder complains that she is feels "driven" to check the locks on her front door at.. Which response is best for the nurse toprovide? A. have you had a bad experience related to unlocked doors? B. What are your thoughts when you are checking the locks? C. feelings of being drive to do something are related to anxiety D. repeating the same behavior helps you to diminish your anxiety - ✔D. repeating the same behavior helps you to diminish your anxiety What is the most important goal for a client with major depression who has been receiving an antidepressant medication for two weeks? A. ventilate feelings of sadness B. eats three meals a day C. participates in group meetings D. does not attempt to commit suicide - ✔D. does not attempt to commit suicide
After meeting with a healthcare provider, a client who is diagnosed with bipolar disorder is screaming and stomping. Which action should the nurse take? A. instruct the client to reduce the volume of his voice B. administer a PRN sedative by injection C. accompany the client to a quiet area of the unit D. encourage the client to attend a support group - ✔C. accompany the client to a quiet area of the unit A client with depression is not attentive to personal hygiene, uses television watching as a means of escape from...inability to enjoy the things that once gave them pleasure. Which coping strategy should the nurse include in the plan of care? A. Relax and reduce the amount of effort to solve the problem B. Recall methods that were most successful in the past C. reach out to family and friends about feelings of abandonment D. turn to other activities to take one's mind off of the issues - ✔B. Recall methods that were most successful in the past A male college student visits the student health center for his annual physical examination. His vital signs and blood glucose...range. His height is 6 feet and 1 inch (185.4 cm), and he weighs 135 pounds (61.36kg). What additional information is most...obtain? A. 24-hour nutritional history B. body mass index C. basal metabolic rate D. complete blood count - ✔B. body mass index A young male who was recently diagnosed with bipolar disorder takes lithium carbonate daily. He is graduating...he tells the school nurse that wants to live away from home for college. What information is most important for...family? A. Despite his illness, the client should be able to live away from home B. his serum lithium levels should be routinely evaluated C. he should plan to participate in group or individual therapy while at college D. he should be aware of the symptoms of his illness - ✔B. his serum lithium levels should be routinely evaluated
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. Dialogue 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. - ✔c. Allow the client to identify the way he interacts. 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 reason for hospitalization - ✔B. Sleep at least 6 hours a night When preparing to administer to domestic violence screening tool to a female client, which statement should the RN provide? A. "If your partner is abusing you, I need to ask these questions." B. "State law mandates that I ask if you are a victim of domestic violence" C. "The HCP provider needs to know if you are experiencing any domestic abuse" D. "All clients are screened for domestic abuse because it is common in our society" - ✔D. "All clients are screened for domestic abuse because it is common in our society" 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? A. "Unless your sister has a medical education, ignore her comments." B. "I can hear that your sister's comments are overwhelming you." C. "Do you think it's possible that you might be a hypochondriac?" D. "Besides your sister's comments, what in life is troubling you?" - ✔D. "Besides your sister's comments, what in life is troubling you?"
The RN is leading a group on the inpatient psychiatric unit. Which approach should the RN use during the working phase of group development? A. Establishing a rapport with group members B. Helping clients identify areas of problem in their lives C. Discussing ways to use new coping skills learned D. Clarifying the nurse's role and clients' responsibilities - ✔B. Helping clients identify areas of problem in their lives A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. What intervention is best for the RN to implement? A. Isolate the client from other clients B. Administer PRN sedative C. Avoid recognizing the behavior D. Escort the client to his room - ✔D. Escort the client to his room 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? A. Pulse rate 68-78 bpm B. BP readings of 90/62 mmHg to 92/ C. Temperature of 99.5-99.7 F D. Respiration rate of 24 bpm - ✔B. BP readings of 90/62 mmHg to 92/ The RN on the evening shift receives report that a client is scheduled for Electroconvulsive Therapy in the morning. Which intervention should the RN implement the evening before the scheduled ECT? A. Keep client NPO after midnight B. Hold all bedtime meds C. Implement elopement precautions D. Give the client an enema at bedtime - ✔A. Keep client NPO after midnight 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. Deep fried shrimp
C. "Expressing your anger to a stranger could result in an unsafe situation" D. "It sounds 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" 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 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 contort into a monster. What action should the nurse take? A. Medicate the client with the prescribed antipsychotic thiordazine (mellaril) B. Offer the client a prescribed physical therapy hot pack for muscle spasms C. Direct client to occupational therapy to distract him for somatic complaints D. Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia - ✔D. Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia 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 the client to the seclusion room B. Quietly approach the client with additional staff members C. Take other client in the area to the client lounge D. Administer medication to chemically restrain client - ✔C. Take other client in the area to the client lounge 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 Which nursing actions are likely to help promote the self-esteem of a male client with moderate depression? (Select all that apply) A. Ask the 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 - ✔C. Include the client in determining treatment protocol D. Encourage the client to engage in recreational therapy A client who is admitted to the mental health unit reports shortness of breath and dizziness. The client tells the nurse, "I feel like I am 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 An adolescent male receives a prescription for an antidepressant drug because he is exhibiting a depressed affect. While the client 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 quality of his attitude C. His level of activity D. The interactions he has with others - ✔B. The emotional quality of his attitude The LPN/LVN calls security and has physical restraints applied when a client who was admitted voluntarily becomes both physically and verbally abusive while demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions? (Select all that apply) A. Libel
C. "Being respectful and concerned will ensure that I'm attentive to my client's rights" D. "Regardless of the client's condition, all nurses have the duty to respect client rights" - ✔C. "Being respectful and concerned will ensure that I'm attentive to my client's rights" A LPN/LVN employed in a mental health unit of a hospital is the leader of a group psychotherapy session. The nurse's role in the termination stage of group development is to: A. Encourage problem solving B. Encourage accomplishment of the group's work C. Acknowledge the contributions of each group member D. Encourage members to become acquainted with one another - ✔C. Acknowledge the contributions of each group member A male client with delirium becomes disoriented and confused in his room at night. The best initial nursing intervention is to: A. Move the client next to the nurse's station B. Use an indirect light source and turn off the television C. Keep the television and a soft light on during the night D. Play soft music during the night and maintain a well-lit room - ✔B. Use an indirect light source and turn off the television A client is admitted to a medical nursing unit with a diagnosis of acute blindness, many tests are performed, and there seems to be no organic reason why this client cannot see. The client became blind after witnessing a hit-and-run car accident, when a family of three was killed. A LPN/LVN suspects that the client may be experiencing: A. Psychosis B. Repression C. Conversion Disorder D. Dissociative Disorder - ✔C. Conversion Disorder A manic client announces to everyone in the day room that a stripper is coming to perform this evening. When a nurse firmly state that this is inappropriate and will not happen, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of the situation, the LPN/LVN determines that the appropriate action would be to: A. Orient the client to time, person, and place B. Tell the client that behavior is inappropriate. C. Escort the manic client to her room with assistance
D. Tell the client that smoking privileges are revoked for 24 hours - ✔C. Escort the manic client to her room with assistance A LPN/LVN observes that a client is pacing, agitated, and presenting aggressive gestures. The client's speech pattern is rapid and affect is belligerent. Based on these observations, the nurse's immediate priority of care is to: A. Provide safety for the client and other clients on the unit B. Provide the clients on the unit with a sense of comfort and safety C. Assist the staff in caring for the client in a controlled environment D. Offer the client a less stimulated area to calm down and gain control - ✔A. Provide safety for the client and other clients on the unit A patient with a diagnosis of major depression who has attempted suicide says to the nurse, "I should have died! I've always been a failure. Nothing ever goes right for me." Which response demonstrates therapeutic communication? A. "You have everything to live for." B. "Why do you see yourself as a failure?" C. "Feeling like this is all part of being depressed." D. "You've been feeling like a failure for a while?" - ✔D. "You've been feeling like a failure for a while?" When the community health nurse visits a patient at home, the patient states, "I haven't slept the last couple of nights." Which response by the nurse illustrates a therapeutic communication response to this patient? A. "I see." B. "Really?" C. "You're having difficulty sleeping?" D. "Sometimes, I have trouble sleeping too." - ✔C. "You're having difficulty sleeping?" A patient experiencing disturbed thought processes believes that his food is has been poisoned. Which communication technique should the nurse use to encourage the patient to eat? A. Using open-ended questions and silence B. Sharing personal preference regarding food choices C. Documenting reasons why the patient does not want to eat D. Offering opinions about the necessity of adequate nutrition - ✔A. Using open-ended questions and silence
When reviewing the admission assessment, the nurse notes that a patient was admitted to the mental health unit involuntarily. Based on this type of admission, the nurse should provide which intervention for this patient? A. Monitor closely for harm to self or others. B. Assist in completing an application for admission C. Supply the patient with written information about their mental illness. D. Provide an opportunity for the family to discuss why they felt the admission was needed. - ✔A. Monitor closely for harm to self or others. The nurse is preparing a patient for the termination phase of the nurse-patient relationship. The nurse prepares to implement which nursing task that is most appropriate for this phase? A. Planning short-term goals B. Making appropriate referrals C. Developing realistic solutions D. Identifying expected outcomes - ✔B. Making appropriate referrals The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbors ask the nurse, "How is Mary doing? She is my best friend and is seen at your clinic every week." Which is the most appropriate nursing response? A. "I can not discuss any patient situation with you." B. "If you want to know about Mary, you need to ask her yourself." C. "Only because you're worried about a friend, I'll tell you that she is improving." D. "Being her friend, you know she is having a difficult time and deserves her privacy." - ✔A. "I can not discuss any patient situation with you." The nurse in the mental health unit recognizes which of the following as therapeutic communication techniques? (Select all that apply) A. Restating B. Listening C. Asking the patient "Why?" D. Maintaining neutral responses E. Providing acknowledgment and feedback F. Giving advice and approval or disapproval - ✔A. Restating B. Listening D. Maintaining neutral responses
E. Providing acknowledgment and feedback A patient's unresolved feelings related to loss would be most likely observed during which phase of the therapeutic nurse-patient relationship? A. Trusting B. Working C. Orientation D. Termination - ✔D. Termination rationale: In the termination phase, the relationship comes to a close. Ending treatment sometimes may be traumatic for patients who have come to value the relationship and the help. Because loss is an issue, any unresolved feelings related to loss may resurface during this phase. Which therapeutic communication technique is being used in this nurse-client interaction? Client: "When I get angry, I get into a fistfight with my wife, or I take it out of the kids." Nurse: "I notice that you are smiling as you talk about this physical violence." A. Encouraging comparison B. Exploring C. Formulating a plan of action D. Making observations - ✔D. Making observations Which therapeutic communication technique is being used in this nurse-client interaction? Client: "My father spanked me often." Nurse: "Your father was a harsh disciplinarian." A. Restatement B. Offering general leads C. Focusing D. Accepting - ✔A. Restatement Which therapeutic communication technique is being used in this nurse-client interaction? Client: "When I am anxious, the only thing that calms me down is alcohol." Nurse: "Other than drinking, what alternatives have you explored to decrease anxiety?" A. Reflecting B. Making observations
