HESI MENTAL HEALTH PROCTORED
Revision Questions & Answers with Rationales
QUES: a 30 year old sales manager tells the nurse "i am thinking about a job change. i don't feel like i am living up to my potential." which of maslows developmental stages is the sales manager attempting to achieve
RATIONALE: selfactualization: self actualization is the highest level of maslows developmental stages, which is an attempt to fulfill ones full potential.. loving and belonging is identifying support systems.. basic needs is the first level of maslows developmental stages and is the foundation upon which higher needs rest.. individuals who feel safe and secure in their environment perceive themselves as having physical safety and lack fear of harm
QUES: the nurse observes a client who is admitted to the mental health unit and identifies that the client is talking continuously, using words that rhyme but have no context or relationship with one topic to the next in the conversation. this clients behavior and thought processes are consistent with which syndrome
RATIONALE schizophrenia : the client is demonstrating symptoms of schizophrenia, such as disorganized speech that may include
word salad (communication that includes both real and imaginary words in no logical order), incoherent speech, and clanging (rhyming).. dementia is a global impairment of intellectual (cognitive) functions that may be progressive, such as alzheimers or organic brain syndrome.. depression is typified
by psychomotor retardation, and the client appears to be slowed down in movement, in speech, and would appear listless and disheveled
QUES: a homeless person who is in the manic phase of bipolar disorder is admitted to the mental health unit.. which lab finding obtained on admission is most important for the nurse to report to the HCP
decreased thyroid stimulating hormone level : hyperthyroidism causes an increased level of serum thyroid hormones (T3 and T4), which inhibit the release of TSH, so the clients manic behavior may be related to an endocrine disorder.. elevated liver function profile, increased WBC count, and decreased hematocrit and hemoglobin levels are abnormal findings that are commonly found in the homeless population because of poor sanitation, poor nutrition, and the prevalence of substance abuse
QUES: an adult male client who was admitted to the mental health unit yesterday tells the nurse that microchips were planted in his head for military surveillance of his every move.. which response is best for the nurse to provide
go to occupational therapy and start a project: delusions often generate fear and isolation, so the nurse should help the client participate in activities that avoid focusing on the false belief and encourage interaction with others.. delusions are often wellfixed, and though saying "you are in a hospital, and i am the nurse caring for you" reinforces reality, it is argumentative and dismisses the clients fears.. it is often difficult for the client to recognize the relationship between delusions and anxiety ("it must be difficult for you to control your anxiety"), and the nurse should reassure the client that he is in a safe place.. dismissing delusional thinking ("you are not in a war now, this is the US"), is unrealistic bc neurochemical imbalances that cause positive symptoms of schizophrenia require antipsychotic drug therapy.
QUES: the nurse is assessing a clients intelligence.. which factor should the nurse remember during this part of the mental status exam
intelligence is influenced by social and cultural beliefs : social and cultural beliefs have significant impact on intelligence.. chronic psychiatric illness may impair intelligence, especially if it remains untreated.. limited concentration does not suggest limited intelligence.. difficulties with abstractions are suggestive of psychotic thinking, not limited intelligence
QUES: at a support meeting of parents of a teenager with polysubstance dependency, a parent states "each time my son tries to quit taking drugs, he gets so depressed that I'm afraid he will commit suicide".. the nurses response should be based on which information
careful monitoring should be provided during withdrawal from the
drugs: the priority is to teach the parents that their son will need monitoring and support during withdrawal to ensure that he does not attempt suicide
QUES: the wife of a male client recently diagnosed with schizophrenia asks the nurse, "what exactly is schizophrenia? is my husband all right?".. which response is best for the nurse to provide
it is a chemical imbalance in the brain that causes disorganized
thinking: the nurse should answer the clients question with
factual information and explain that schizophrenia is a
chemical imbalance in the brain
QUES: a young adult male client, diagnosed with paranoid schizophrenia, believes that the world is trying to poison him.. what intervention should the nurse include in this clients plan of care
ask one nurse to spend time with the client daily: a client with paranoid schizophrenia has difficulty with trust and developing a trusting relationship with one nurse is likely to be therapeutic for this client
QUES: the community health nurse talks to a male client who has bipolar disorder.. the client explains that he sleeps 4 5 hours a night and is working with his partner to start two new businesses and build an empire.. the client stopped taking his meds several days ago.. what nursing problem has the highest priority
medication mgmt : the most important nursing problem is medication mgmt because compliance with the medication regimen will help prevent hospitalization
Revision Questions & Answers with Rationales
QUES: a 30 year old sales manager tells the nurse "i am thinking about a job change. i don't feel like i am living up to my potential." which of maslows developmental stages is the sales manager attempting to achieve
RATIONALE: selfactualization: self actualization is the highest level of maslows developmental stages, which is an attempt to fulfill ones full potential.. loving and belonging is identifying support systems.. basic needs is the first level of maslows developmental stages and is the foundation upon which higher needs rest.. individuals who feel safe and secure in their environment perceive themselves as having physical safety and lack fear of harm
QUES: the nurse observes a client who is admitted to the mental health unit and identifies that the client is talking continuously, using words that rhyme but have no context or relationship with one topic to the next in the conversation. this clients behavior and thought processes are consistent with which syndrome
RATIONALE schizophrenia : the client is demonstrating symptoms of schizophrenia, such as disorganized speech that may include
word salad (communication that includes both real and imaginary words in no logical order), incoherent speech, and clanging (rhyming).. dementia is a global impairment of intellectual (cognitive) functions that may be progressive, such as alzheimers or organic brain syndrome.. depression is typified
by psychomotor retardation, and the client appears to be slowed down in movement, in speech, and would appear listless and disheveled
QUES: a homeless person who is in the manic phase of bipolar disorder is admitted to the mental health unit.. which lab finding obtained on admission is most important for the nurse to report to the HCP
decreased thyroid stimulating hormone level : hyperthyroidism causes an increased level of serum thyroid hormones (T3 and T4), which inhibit the release of TSH, so the clients manic behavior may be related to an endocrine disorder.. elevated liver function profile, increased WBC count, and decreased hematocrit and hemoglobin levels are abnormal findings that are commonly found in the homeless population because of poor sanitation, poor nutrition, and the prevalence of substance abuse
QUES: an adult male client who was admitted to the mental health unit yesterday tells the nurse that microchips were planted in his head for military surveillance of his every move.. which response is best for the nurse to provide
go to occupational therapy and start a project: delusions often generate fear and isolation, so the nurse should help the client participate in activities that avoid focusing on the false belief and encourage interaction with others.. delusions are often wellfixed, and though saying "you are in a hospital, and i am the nurse caring for you" reinforces reality, it is argumentative and dismisses the clients fears.. it is often difficult for the client to recognize the relationship between delusions and anxiety ("it must be difficult for you to control your anxiety"), and the nurse should reassure the client that he is in a safe place.. dismissing delusional thinking ("you are not in a war now, this is the US"), is unrealistic bc neurochemical imbalances that cause positive symptoms of schizophrenia require antipsychotic drug therapy.
QUES: the nurse is assessing a clients intelligence.. which factor should the nurse remember during this part of the mental status exam
intelligence is influenced by social and cultural beliefs : social and cultural beliefs have significant impact on intelligence.. chronic psychiatric illness may impair intelligence, especially if it remains untreated.. limited concentration does not suggest limited intelligence.. difficulties with abstractions are suggestive of psychotic thinking, not limited intelligence
QUES: at a support meeting of parents of a teenager with polysubstance dependency, a parent states "each time my son tries to quit taking drugs, he gets so depressed that I'm afraid he will commit suicide".. the nurses response should be based on which information
careful monitoring should be provided during withdrawal from the
drugs: the priority is to teach the parents that their son will need monitoring and support during withdrawal to ensure that he does not attempt suicide
QUES: the wife of a male client recently diagnosed with schizophrenia asks the nurse, "what exactly is schizophrenia? is my husband all right?".. which response is best for the nurse to provide
it is a chemical imbalance in the brain that causes disorganized
thinking: the nurse should answer the clients question with
factual information and explain that schizophrenia is a
chemical imbalance in the brain
QUES: a young adult male client, diagnosed with paranoid schizophrenia, believes that the world is trying to poison him.. what intervention should the nurse include in this clients plan of care
ask one nurse to spend time with the client daily: a client with paranoid schizophrenia has difficulty with trust and developing a trusting relationship with one nurse is likely to be therapeutic for this client
QUES: the community health nurse talks to a male client who has bipolar disorder.. the client explains that he sleeps 4 5 hours a night and is working with his partner to start two new businesses and build an empire.. the client stopped taking his meds several days ago.. what nursing problem has the highest priority
medication mgmt : the most important nursing problem is medication mgmt because compliance with the medication regimen will help prevent hospitalization
