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Foundations and Practice of Mental
Health Nursing HESI EXIT 2
Questions and Correct Answers the
Latest Update
A 3-year-old child is brought to the emergency department by the mother, who
reports that her child fell down the stairs and sustained injuries to the right arm
and leg. During the physical assessment the nurse identifies a number of old
bruises on the child's back, buttocks, and upper arms. What should the nurse
say to the child to obtain additional information?
✓ "Show me how you fell down the stairs."
A nurse is caring for several clients who have severe psychiatric disorders. What
is the major reason that a health care provider prescribes an antipsychotic
medication for these clients?
✓ To reduce the positive symptoms of psychosis
A client with mental health problems is given a prescription for fluphenazine
(Prolixin). The nurse develops a teaching plan about the medication. What
should the nurse caution the client to avoid?
✓ Staying in the sun
When a newly admitted client with paranoid ideation tells the nurse about
people coming through the doors to commit murder, the nurse should:
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✓ Listen to what the client is saying.
A nurse is evaluating the medication regimens of clients to determine whether
the therapeutic levels have been achieved. For which medication should the
nurse review the client's serum blood level?
✓ Valproic acid (Depakene)
It is most helpful to the nurse who is attempting to apply the principles of
mental health to consider that:
✓ Emotional health is promoted when there is a sense of mastery of self and the
environment.
A health care provider writes a prescription of "Restraints PRN" for a client who
has a history of violent behavior. What is the nurse's responsibility in regard to
this order?
✓ Recognizing that PRN orders for restraints are unacceptable
What is the most important tool a nurse brings to the therapeutic nurse-client
relationship?
✓ The self and a desire to help
A 34-year-old woman who was sexually assaulted is examined in the emergency
department within 2 hours of the assault. During assessment she freely discusses
the incident, her past psychiatric history, and her past sexual history with the
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sexual assault nurse examiner (SANE). Which information documented by the
nurse indicates that the nurse needs more teaching about appropriate charting?
✓ Details of the client's sexual history
A young adult client is hospitalized with a spinal cord injury. The client, knowing
that the paralysis may be permanent, says, "I wish God would end my suffering
and take me." What is the most therapeutic initial response by the nurse?
✓ Being incapacitated is difficult for you."
A client has been taking escitalopram (Lexapro) for treatment of a major
depressive episode. On the fifth day of therapy the client refuses the medication,
stating, "It doesn't help, so what's the use of taking it?" What is the best
response by the nurse?
✓ "It can take 1 to 4 weeks to see an improvement."
During a group therapy session some members accuse another client of
intellectualizing to avoid discussing feelings. The client asks whether the nurse
agrees with the others. What is the best response by the nurse?
✓ Are you uncomfortable with what you were told?"
A client is presented with the treatment option of electroconvulsive therapy
(ECT). After discussion with staff members, the client requests that a family
member be called to help make the decision about this treatment. What ethical
principle does the nurse consider when supporting the client's request?
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✓ Autonomy
A client on the psychiatric unit who has suicidal ideas says to the nurse, "I signed
myself in. I'll sign myself out." What concept provides the basis for the nurse's
response?
✓ Suicidal clients may not sign out even if they voluntarily admitted themselves.
A client with type 1 diabetes is found to have a psychosis and is to receive
haloperidol (Haldol). Which response should a nurse anticipate with this drug
combination?
✓ Decreased control of the diabetes
A client on the psychiatric unit sits alone most of the day. The nurse approaches
the client. As the nurse gets approximately 3 feet away, the client lets out a
string of profanity and shouts, "Leave me alone; I don't want to talk to you!"
What is the most appropriate response by the nurse?
✓ I'll leave for now, but I'll be back later."
A nurse determines that confrontation is an appropriate tool for use with a
client. What is an example of therapeutic confrontation?
✓ You say you're not a good parent, but you were effective when you were talking
with your son today
A nurse assessing the behavior of the parents of a physically maltreated child
expects that the parents will:
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Foundations and Practice of Mental
Health Nursing HESI EXIT 2
Questions and Correct Answers the
Latest Update
A 3-year-old child is brought to the emergency department by the mother, who
reports that her child fell down the stairs and sustained injuries to the right arm
and leg. During the physical assessment the nurse identifies a number of old
bruises on the child's back, buttocks, and upper arms. What should the nurse
say to the child to obtain additional information?
✓ "Show me how you fell down the stairs."
A nurse is caring for several clients who have severe psychiatric disorders. What
is the major reason that a health care provider prescribes an antipsychotic
medication for these clients?
✓ To reduce the positive symptoms of psychosis
A client with mental health problems is given a prescription for fluphenazine
(Prolixin). The nurse develops a teaching plan about the medication. What
should the nurse caution the client to avoid?
✓ Staying in the sun
When a newly admitted client with paranoid ideation tells the nurse about
people coming through the doors to commit murder, the nurse should:
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✓ Listen to what the client is saying.
A nurse is evaluating the medication regimens of clients to determine whether
the therapeutic levels have been achieved. For which medication should the
nurse review the client's serum blood level?
✓ Valproic acid (Depakene)
It is most helpful to the nurse who is attempting to apply the principles of
mental health to consider that:
✓ Emotional health is promoted when there is a sense of mastery of self and the
environment.
A health care provider writes a prescription of "Restraints PRN" for a client who
has a history of violent behavior. What is the nurse's responsibility in regard to
this order?
✓ Recognizing that PRN orders for restraints are unacceptable
What is the most important tool a nurse brings to the therapeutic nurse-client
relationship?
✓ The self and a desire to help
A 34-year-old woman who was sexually assaulted is examined in the emergency
department within 2 hours of the assault. During assessment she freely discusses
the incident, her past psychiatric history, and her past sexual history with the
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sexual assault nurse examiner (SANE). Which information documented by the
nurse indicates that the nurse needs more teaching about appropriate charting?
✓ Details of the client's sexual history
A young adult client is hospitalized with a spinal cord injury. The client, knowing
that the paralysis may be permanent, says, "I wish God would end my suffering
and take me." What is the most therapeutic initial response by the nurse?
✓ Being incapacitated is difficult for you."
A client has been taking escitalopram (Lexapro) for treatment of a major
depressive episode. On the fifth day of therapy the client refuses the medication,
stating, "It doesn't help, so what's the use of taking it?" What is the best
response by the nurse?
✓ "It can take 1 to 4 weeks to see an improvement."
During a group therapy session some members accuse another client of
intellectualizing to avoid discussing feelings. The client asks whether the nurse
agrees with the others. What is the best response by the nurse?
✓ Are you uncomfortable with what you were told?"
A client is presented with the treatment option of electroconvulsive therapy
(ECT). After discussion with staff members, the client requests that a family
member be called to help make the decision about this treatment. What ethical
principle does the nurse consider when supporting the client's request?
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✓ Autonomy
A client on the psychiatric unit who has suicidal ideas says to the nurse, "I signed
myself in. I'll sign myself out." What concept provides the basis for the nurse's
response?
✓ Suicidal clients may not sign out even if they voluntarily admitted themselves.
A client with type 1 diabetes is found to have a psychosis and is to receive
haloperidol (Haldol). Which response should a nurse anticipate with this drug
combination?
✓ Decreased control of the diabetes
A client on the psychiatric unit sits alone most of the day. The nurse approaches
the client. As the nurse gets approximately 3 feet away, the client lets out a
string of profanity and shouts, "Leave me alone; I don't want to talk to you!"
What is the most appropriate response by the nurse?
✓ I'll leave for now, but I'll be back later."
A nurse determines that confrontation is an appropriate tool for use with a
client. What is an example of therapeutic confrontation?
✓ You say you're not a good parent, but you were effective when you were talking
with your son today
A nurse assessing the behavior of the parents of a physically maltreated child
expects that the parents will:
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