Mental Health Hesi 2

MENTAL Health HESI 2 1. A male employee who is assessed weekly in the employee clinic for blood pressure because of a history of hypertension tells the nurse that he is so upset with one of his co-workers that he would like to shoot him. What action should the nurse take first? a.) Determine if the client has a weapon available for use. b.) Inform the health care provider of the threat to harm a co-worker. c.) Notify security of the client’s intention to harm a co-worker. d.) Have the employee escorted to a mental health facility. 2. A male client who is participating in an anger management assignment asks if he can make a leather belt in occupational therapy. The client begins pounding the leather vigorously with a mallet to imprint designs on the belt. What defense mechanism is the client using? a.) Sublimation. b.) Suppression. c.) Regression. d.) Compensation. 3. A 20-year-old female client with schizophrenia is scheduled to receive risperidone (Risperdal) 2mg at bedtime. When the nurse attempts to administer the medication, the client states. “I am not going to take that medicine, and you can’t make me.” What action should the nurse take? a.) Administer the medication via a nasogastric tube. b.) Substitute an injectable form of the medication. c.) Encourage the client to take the medicine because it will help her sleep. d.) Document in the client’s record that the medication was refused. 4. An adult female client tells the nurse that though she is afraid her abusive boyfriend might one day kill her, she keeps hoping that he will change. What action should the nurse take first? a.) Discuss treatment options for abusive partners. b.) Explore client’s readiness to discuss the situation. c.) Determine the frequency and type of client’s abuse. d.) Report the finding to the police department. 5. A male client with bipolar disorder has not slept or eaten in four days. He paces and becomes increasingly agitated and loud while the nurse talks to his spouse. What intervention is the best for the nurse to implement at this time? a.) Move to a quiet area and provide peanut butter with crackers. b.) Walk with the client to the cafeteria and star as he eats lunch. c.) Request a full lunch tray from the dietary department. d.) Encourage the spouse to eat lunch with the client. 6. The nurse asks a female client with a borderline personality disorder, “How do you feel about your children not coming to visit this weekend?” The client looks out the window and replies, “I really don’t care.” Which response is best for the nurse to provide? a.) “I noticed you were looking out the window when discussing your feelings.” b.) “I think you’re lying and it bothers you that your children aren’t coming.” c.) “I think you should discuss your children not coming in the group meeting.” d.) “Why do you think your children didn’t want to come visit you this weekend?” 7. What is the most important goal of care for a client diagnosed with generalized anxiety disorder (GAD) who has been taking the benzodiazepine alprazolam (Xanax) long-term? The client will a.) Describe a decrease in anxiety using a 1 to 10 anxiety scale. b.) State the importance of not abruptly stopping the medication. c.) Not experience dizziness, lightheadedness, or sedation. d.) Attend scheduled individual and group therapy sessions. 8. The nurse is performing intake interviews at a psychiatric clinic. A female client with a known history of drug abuse reports that she has a heart attack four years ago. Use of which substance abuse places the client at highest risk for myocardial infarction. a.) Benzodiazepine b.) Marijuana c.) Methamphetamine d.) Alcohol 9. During a one-to-one session with the nurse, a female client who has been admitted for chronic depression and attempted suicide discloses her experience of sexual promiscuity and prostitution. When the nurse asks the client if she was ever sexually abused as a child, the client says, “I don’t remember, but my mother ran my father off when I was five.” The nurse should recognize that the client may be using which defense mechanism? a.) Denial b.) Projection c.) Regression d.) Repression 10. A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words and wanders into client’s room. The nurse decides that the client needs constant observation based on which of these assessment findings? a.) Disrupts group activities. b.) Wanders into the client’s rooms. c.) Talks with nonsensical words. d.) Refuses antipsychotic medications. 11. A women is brought to the psychiatric clinic by her husband who reports that his wife is reluctant to leave home because of what she describes as fear of open places and crowds. What is the best nursing diagnosis for this client? a.) High risk for injury related to chronic depression. b.) Anxiety related to poor self-image. c.) Ineffective individual coping. d.) High risk for injury related to isolation. 12. The atypical antipsychotic ziprasidone (Geodon) is prescribed for a client with a medical diagnosis of schizophrenia. After the client has been taking the medication for two weeks, the nurse assesses the drug’s effectiveness. Which client report suggests that the medication is helpful? a.) Is feeling less depressed? b.) Sleeps better at night. c.) The voices are quieter. d.) Nervousness has decreased. 13. A male college student brings his roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that the voices are saying, “kill kill.” What question should the nurse ask the client next? a.) “When did these voices begin?” b.) “Have you taken any hallucinogens?” c.) “Are you planning to obey the voices?” d.) “Do you believe the voices are real?” 14. A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone (Risperdal). When the client walks to the nurse’s station in a laterally contracted position, he states that something has made his body contort into a monster. What action should the nurse take? a.) Medicate the client with the prescribed PRN antipsychotic trifluoperazine (Stela zine). b.) Offer the client a prescribed physical therapy treatment of hot pack for muscle spasms. c.) Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia. d.) Direct the client to occupational therapy to distract him from somatic complaints. 15. The nurse on the evening shift received report that a client is scheduled for electroconvulsive treatment (ECT) in the morning. Which interventions should the nurse implement the evening before the scheduled ECT? a.) Implement elopement precautions. b.) Keep the client NPO after midnight. c.) Give client an enema at bedtime. d.) Hold all bedtime medications. 16. During the initial nursing interview, a client tells the nurse, “Sometimes my thoughts go so fast. Wonder if I can sell my fast car. Work is so boring. I wonder if I can get a transfer. Is it time to eat yet?” Which documentation should the nurse use to describe the client’s statements? a.) Demonstrates thought-blocking. b.) Uses incoherent speech. c.) Exhibits tangential thinking. d.) Displays the use of word salad. 17. A chronically depressed older male resident of a long-term care facility has become more reclusive and today refuses to leave his room. His family moved away from the local area and they are unable to visit as much as they had in the past. Which comment by the nurse is like to be most helpful to this client? a.) “May I sit with you for a while?” b.) “I know you are sad about not seeing your family as often, but they are visiting as much as they can.” c.) “Come into the recreation area. We have your favorite card game and I will play it with you.” d.) “Why do you want to stay in your room today?” 18. A client with borderline personality disorder tells the nurse, “You are the best nurse on the unit! The other nurses don’t care about me the way you do.” Which response is best for the nurse to provide this client? a.) “I am not the best nurse. All the nurses are good.” b.) “The other nurses and I are here to help you get better” c.) “You don’t think the other nurses care about you?” d.) “I do care about you as a person but nothing more.” 19. A male client who is admitted with bipolar disorder( manic psychosis), is placed in seclusion after unsuccessful attempts to de-escalate him during a sudden mood swing from laughter to jumping and screaming threats while having a plastic dinner knife. The client is given haloperidol (Haldol) 5 mg IM STAT prior to seclusion. What intervention is most important for the nurse to implement immediately after seclusion? a.) Observe for extrapyramidal symptoms, such as dystonia. b.) Release the client as soon as composure is regained. c.) Provide one-on-one observation at all times. d.) Secure the room with padded walls and minimal furnishings. 20. The nurse notes that a depressed female client has been more withdrawn and no communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client? a.) Engage the client in non-threatening conversations. b.) Schedule a daily conference with the social worker. c.) Encourage the client’s family to visit more often. d.) Encourage the client to participate in group activities. ..........................................................