- Information
- AI Chat
HESI RN Mental Health 2022 - 2023
Rn Collaborative Healthcare (NR-447)
Chamberlain University
Preview text
HESI RN MENTAL HEALTH V2 Latest Update 2022/
GRADED A+
A client with depression remains in bed most of the day, declines activities and refuses meals. 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.
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 (Cogentin) c. Alprazolam (Xanax) d. Magnesium (milk of magnesia)
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 nonverbal communication. What action should the nurse take? a. Pay close attention and docum ent 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 male client approaches the nurse with an angry expression 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 onemore 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
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 client’s serum lithium level to the healthcare provider b. Encourage the client to suck on hard candy to relieve the symptoms c. No actions is needed since polydipsia is a common side effect d. Tell the client that drinking from the faucet is not allowed
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 abuser
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 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 sounds or voices that others do not hear?
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” d. It sound 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
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) Tortured animals as a child. C) Was physically abused by his mother D) Hates to be touched by anyone 15. 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 16. 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. 17. 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 18. 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. 19. 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)
A) Have a bag ready that has extra clothes for self and children. B) Establish a code with family and friend to signify violence. C) Purchase a gun to use for protection D) Take a self-defense course that retaliate the abuser with injury. E) Plan an escape route to use if the abuser blocks the main exit. 20. 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 A) Offer the client a safe place to relax before interviewing her. B) Ask the client to describe why she is being stalked. C) Recommend that the client talk with a social worked. D) Assure client that the healthcare provider will see her today. 21 nurse leading a group session of adolescent client 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) Explore the client’s feelings about his pet and home life. B) Encourage his peers to help involve him in the activity. C) Give the client perm ission to leave and return in 10 m in. D) Redirect him by encouraging him to read from the handout. 22. 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. 23. 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. 24. 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.
alcohol level (BAL)is 0 mg/dl. Which prescription should the nurse administer? A) Haloperidol (Haldol) B) Thiamine (Vit B1) C) Diphenhydramine (Benadryl) D) Lorazepan (Ativan) 30. 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 31 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. 32 client statement suggests 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) I want to be here because I know it is the best psychiatric facility” C) At least I hit the wall instead of hitting the psychiatric aide” D) Don’t believe everything my family tells you, I am not crazy” 33 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) M y 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” 34. 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 to develop a list of pleasurable activities C) Teach the client to develop a plan for daily structured activities D) Provide education on methods to enhance sleep 35. 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. 36 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 be reduce B) Co- dependent behaviors will be decreased C) Client’s level of consciousness will increase. D) Client will not demonstrate cross- addiction 37 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 the disturbance, the client shouts, “I am the boss here. I do what I want” which nursing problem best supports these observation? A) Deficient diversional activity related to excess energy level B) Disturbed personal identity related to grandiosity C) Risk for activity intolerance related to hyperactivity D) Risk for other related violence related to disruptive behaviors 38. 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 tim e? 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 39. Following surgery, a male client with antisocial personality disorder frequently request that a specific nurse be assigned to his care and is
B) Sometime client feel like the TV is sending them messages C) It’s 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 44 client who is admitted with a closed head injury after a fall has a blood alcohol level (BAL) of 0 (28%) and is difficult to arouse. Which intervention during the first 6 h following admission should the nurse identify as the priority? A) Give lorazepan ( Ativan) PRN for signs of withdrawal B) Administer disulfiram (antabuse) immediately C) Place in side-lying position with head of bed elevated D) Provide thiamine and folate supplements as prescribed 45 nurse is using the CAGE questionnaire as a screening tool for a client who is seeking helpbecause his wife said he had a drinking problem. What information should the nurse explore indepth with the client based on this screening tool? A) Cancer screening result angerv gastritis daily alcohol intake. B) Consumptiom, liver enzyme gastrointestinal complaints and bleeding C) Efforts to cut down annoyance with question guilt drinking as an eye opener D) Minimizes drinking frequently misses family event guilt about drinking amount of daily intake 46 female client engages in repeated checks of door and a window lock behavior that prevents her from 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 47. 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 48. The nurse is completing the admission assessment of and underweight adolescent who is 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 mm D) Body mass index of 21 49. 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 50 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 problem s?” C) When was the last tim e you drank an alcoholic beverage?” D) Do you have a history of angina or high BP?” 51 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 in the client plan of care? A) Implement behaviors modification therapy. B) Indicate caloric and nutritional therapy. C) Evaluate the client for low self- esteem. D) Record daily weights and graft trend. 52 interviewing a client, the nurse takes notes to assist with accurate documentation later. Which statement is most accurate regarding note-take during an interview? A) The client’s comfort level is increased when the nurse breaks eye contact to take notes. B) The interview process is enhanced with note taking and allows the client’s to speak at a normal pace. C) Taken note during an interview is a legal obligation of the examining nurse. D) The nurse’s ability to directly observe the client’s nonverbal communication is limited with note taking. 53 male client with bipolar disorder tells the nurse that the needs to “ make some deals so that he can improve his retirement savings “
REPEAT OF THE QUESTIONS ABOVE:
A client with depression remains in bed most of the day, and declines activities,. 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.
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).
A female client requests that her husband be allowed to stay in the room during the admission assessment. When interviewing the client, the RN notes a discrepancy between the client’s verbal and nonverbal communication. What action does the RN 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 male client approaches the RN with an angry expression 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 RN recognizes that the client is using which defense mechanism? A. Denial. B. Projection. C. Rationalization. D. Splitting.
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.
The RN is teaching a client about the initiation of the 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 for 12 hours prior to the first dose. C. Attend monthly meetings of alcoholics anonymous. D. Admit to others that he is a substance user.
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 RN 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 sounds or voices that others do not hear?
During an annual physical by the occupational RN working in a corporate clinic, a male employee tells the RN that is high-stress job is causing trouble in his personal life. He further explains that he often gets so angry while driving to and from work that he has considered “getting even” with other drivers. How should the RN respond? A. “Anger is contagious and could result in major confrontation.” B. “Try not to let your anger cause you to act impulsively.”
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 loid voice to talk to the client. D. Remains at a distance of 4 feet from the client.
A client on the mental health unit is becoming more agitated, shoutingat the staff, and pacing in the hallway. When the PRN medication is offered, the client refuses the medication and defiantly sits on the floor inthe middle of he unit hallway. What nursing intervention should the RN implement first? A. Transport of the client to the seclusion room. B. Quietly approach the client with additional staff members. C. Take other clients in the area to the client lounge. D. Administer medication to chemically 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. “W hat 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.”
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? 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.
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 the television talks to her. The RN should document these assessment findings in which section of the mental status exam/ A. Level of concentration. B. Insight and judgement. C. Remote memory. D. Mood and affect.
A client is admitted to the mental health unit reports shortness of breath and dizziness. The client tells the RN, “I feel like I’m going to die”. Which nursing problem should the RN include in this client’s plan of care? A. Mood disturbance. B. Moderate anxiety. C. Altered thoughts. D. Social isolation.
A female client who is wearing dirty clothes and has foul body odor, comes to the clinic reporting feeling scared because she is being stalked. What action is most important for the RN to take? A. Offer the client a safe place to relax before interviewing her. B. Ask the client to describe why she is being stalked. C. Recommend that the client talk with a social worker. D. Assure the client that the HCP will see her today.
The RN 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 RN to take? A. Explore the client’s feelings about his pets and home life. B. Encourage his peers to help involve him in the activity. C. Give the client permission to leave and return in 10 minutes. D. Redirect him by encouraging him to read from the handout.
A male adolescent was admitted to the unit two days ago for depression. When the mental health RN tries to interview the client to
50.
A client who is known to abuse drugs is admitted to the psychiatric unit. Which medication should the nurse anticipate administering to a client who is exhibiting benzodiazepine withdrawal symptoms? A) Perphenazine (Trilafon). B) Diphenhydramine (Benadryl). C) Chlordiazepoxide (Librium). D) Isocarboxazid (Marplan).
Librium (C), an antianxiety drug, as well as other benzodiazepines, are used in titrated doses to reduce the severity of abrupt benzodiazepine withdrawal. (A) is an antipsychotic agent. (B) is an antihistamine and antianxiety drug. (D) is an MAO inhibitor.
Correct Answer(s): C
- A male client who recently lost a loved one arrives at the mental health center and tells the RN he is no longer interested is his usual activities and has not slept for several days. Which priority nursing problem should the RN include in the client’s plan of care?
A. Risk for suicide. B. Sleep deprivation. C. Situational low self-esteem. D. Social isolation.
- A male client with long history of alcohol dependency arrives in the emergency department describing the feelings of bugs crawling on his body. His blood pressure is 170/102, his pulse rate is 110 bpm, and is blood alcohol level is 0mg/dL. Which prescription should the RN administer?
A. Haloperidol (Haldol). B. Thiamine (Vitamin B1). C. Diphenhydramine (Benadryl). D. Lorazepam (Ativan).
- A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words and wanders into client’s rooms.
The RN decides that the client needs constant observation based on which of these assessment findings?
A. Wanders into the clients rooms. B. Refuses antipsychotic medications. C. Talks with nonsensical words. D. Disrupts group activities.
- 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.”
- 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?
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.
- Narcan was administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate (Vicodin). Within 15 minutes, the client is alert and oriented. In planning nursing care, which intervention has the highest priority at this tim e?
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.
- Following surgery, a male client with antisocial personality disorder frequently requests that a specific RN be assigned to is care and is
HESI RN Mental Health 2022 - 2023
Course: Rn Collaborative Healthcare (NR-447)
University: Chamberlain University
This is a preview
Access to all documents
Get Unlimited Downloads
Improve your grades
