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MENTAL HESI V6 2021
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MENTAL HESI 6
Psychiatric Hesi book
1. A nurse working in the emergency department of a children's hospital admits a child whose
injuries could have been the result of abuse. Which statement most accurately describes the
nurse's responsibility in cases of suspected child abuse?
A. Obtain objective data such as radiographs before reporting suspicions.
B. Confirm suspicions of abuse with the healthcare provider.
C. Report any case of suspected child abuse.
D. Document injuries to confirm suspected abuse.
Rationale:
It is the nurse's legal responsibility to report all suspected cases of child abuse (C), and notifying
the nurse manager or charge nurse starts the legal reporting process. (A, B, and D) delay the
first step in reporting the abuse.
2. An 8-year-old child is seen in the clinic with a green vaginal discharge. What action is most
important for the nurse to implement?
A. Assess the child's blood pressure.
B. Counsel the child to wear cotton underwear.
C. Report as suspected child abuse.
D. Determine if the child takes bubble baths.
Rationale:
A green vaginal discharge is indicative of gonorrhea, a sexually transmitted disease. Since the
child is 8 years old, the nurse should suspect child abuse and report the incident to the proper
authorities (C). (A) is usually not related to infection. (B and D) are helpful in preventing bladder
infections, but a green vaginal discharge is not a symptom of a bladder infection.
3. On admission, a highly anxious client is described as delusional. The nurse understands that
delusions are most likely to occur with which disorder?
A. Dissociative disorders
B. Personality disorders
C. Anxiety disorders
D. Psychotic disorders
Rationale:
Delusions are false beliefs characteristic of psychosis (D). Delusions are generally not
characteristic of (A, B, and C).
4. Over a period of several weeks, one male participant of a socialization group at a
community daycare center for older adults monopolizes most of the group's time and
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interrupts others when they are talking. What is the best action for the nurse to take in this
situation?
A. Talk to him outside the group about his behavior.
B. Ask him to give others a chance to talk.
C. Allow the group to handle the problem.
D. Ask him to join another group.
Rationale:
After several weeks, the group is in the working phase and the group members should be
allowed to determine the direction of the group. The nurse should ignore the comments and
allow the group to handle the situation (C). A good leader should not have separate meetings
with group members (A), as such behavior is manipulative on the part of the leader. (B) is
dictatorial and is not in keeping with good leadership skills. (D) is avoiding the problem.
Remember, identify what phase the group is in (initial, working, or termination) as an aid to
determining expected communication style.
5. A 22-year-old female client is admitted to the psychiatric unit from the medical unit
following a suicide attempt with an overdose of diazepam (Valium). When developing the
nursing care plan for this client, what intervention would be most important to include?
A. Assist her to focus on her strengths.
B. Set limits on her self-defacing comments.
C. Remind her of daily activities in the milieu.
D. Assist her to identify why she was self-destructive.
Rationale:
Encouraging the client to focus on her strengths (A) helps her become aware of her positive
qualities, assists in improving her self-image, and aids her in coping with past and present
situations. Although nursing actions should assist the client in decreasing (B) and inform the
client of (C), these interventions are not a priority at this time. (D) is not as important as
assisting her to overcome the depression, which resulted in the overdose, and asking "why" is
nontherapeutic.
6. The nurse reviews the laboratory findings for a client's urine drug screen that is positive for
cocaine. Which client behavior should be expected during cocaine withdrawal?
A. Psychomotor impairment
B. Agitation and hyperactivity
C. Detachment from reality and drowsiness
D. Distorted perceptions and hallucinations
Rationale:
During cocaine withdrawal, the nurse should expect (A) and a pattern of withdrawal symptoms
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MENTAL HESI V6 2021
For more test banks, exams, books visit pasinggrades.co
Downloaded by: Ariah |
Distribution of this document is illegal
, Stuvia.com - The Marketplace to Buy and Sell your Study Material
MENTAL HESI 6
Psychiatric Hesi book
1. A nurse working in the emergency department of a children's hospital admits a child whose
injuries could have been the result of abuse. Which statement most accurately describes the
nurse's responsibility in cases of suspected child abuse?
A. Obtain objective data such as radiographs before reporting suspicions.
B. Confirm suspicions of abuse with the healthcare provider.
C. Report any case of suspected child abuse.
D. Document injuries to confirm suspected abuse.
Rationale:
It is the nurse's legal responsibility to report all suspected cases of child abuse (C), and notifying
the nurse manager or charge nurse starts the legal reporting process. (A, B, and D) delay the
first step in reporting the abuse.
2. An 8-year-old child is seen in the clinic with a green vaginal discharge. What action is most
important for the nurse to implement?
A. Assess the child's blood pressure.
B. Counsel the child to wear cotton underwear.
C. Report as suspected child abuse.
D. Determine if the child takes bubble baths.
Rationale:
A green vaginal discharge is indicative of gonorrhea, a sexually transmitted disease. Since the
child is 8 years old, the nurse should suspect child abuse and report the incident to the proper
authorities (C). (A) is usually not related to infection. (B and D) are helpful in preventing bladder
infections, but a green vaginal discharge is not a symptom of a bladder infection.
3. On admission, a highly anxious client is described as delusional. The nurse understands that
delusions are most likely to occur with which disorder?
A. Dissociative disorders
B. Personality disorders
C. Anxiety disorders
D. Psychotic disorders
Rationale:
Delusions are false beliefs characteristic of psychosis (D). Delusions are generally not
characteristic of (A, B, and C).
4. Over a period of several weeks, one male participant of a socialization group at a
community daycare center for older adults monopolizes most of the group's time and
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interrupts others when they are talking. What is the best action for the nurse to take in this
situation?
A. Talk to him outside the group about his behavior.
B. Ask him to give others a chance to talk.
C. Allow the group to handle the problem.
D. Ask him to join another group.
Rationale:
After several weeks, the group is in the working phase and the group members should be
allowed to determine the direction of the group. The nurse should ignore the comments and
allow the group to handle the situation (C). A good leader should not have separate meetings
with group members (A), as such behavior is manipulative on the part of the leader. (B) is
dictatorial and is not in keeping with good leadership skills. (D) is avoiding the problem.
Remember, identify what phase the group is in (initial, working, or termination) as an aid to
determining expected communication style.
5. A 22-year-old female client is admitted to the psychiatric unit from the medical unit
following a suicide attempt with an overdose of diazepam (Valium). When developing the
nursing care plan for this client, what intervention would be most important to include?
A. Assist her to focus on her strengths.
B. Set limits on her self-defacing comments.
C. Remind her of daily activities in the milieu.
D. Assist her to identify why she was self-destructive.
Rationale:
Encouraging the client to focus on her strengths (A) helps her become aware of her positive
qualities, assists in improving her self-image, and aids her in coping with past and present
situations. Although nursing actions should assist the client in decreasing (B) and inform the
client of (C), these interventions are not a priority at this time. (D) is not as important as
assisting her to overcome the depression, which resulted in the overdose, and asking "why" is
nontherapeutic.
6. The nurse reviews the laboratory findings for a client's urine drug screen that is positive for
cocaine. Which client behavior should be expected during cocaine withdrawal?
A. Psychomotor impairment
B. Agitation and hyperactivity
C. Detachment from reality and drowsiness
D. Distorted perceptions and hallucinations
Rationale:
During cocaine withdrawal, the nurse should expect (A) and a pattern of withdrawal symptoms
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