NSG 322 PRACTICE HESI
1. A client with substance abuse is admitted to the mental health unit. Whichaction should be
implemented by the nurse, and not delegated to a unlicensedassistive personnel (UAP)?
Answer: Collect a complete substance abuse history.
2. A female client with bipolar disorder, manic phase, is planning weekend activities with
the other clients on the unit. The client interrupts the group, insists that they change their plans
to a disco party, and begins to curse loudlywhen the group refuses to change the plans. Which
intervention should the nurse implement?
Answer: Escort the client to a quieter place
3. A client with a history of alcoholism is admitted with a compound fractureof the femur
after falling down the previous night.What additional assessmentshould be the priority focus
for the nurse?
Answer: Ask the client about the quantity, frequency, and time the last alcohol drink was
ingested.
4. The nurse is caring for a client who was admitted for alcohol detoxification2 days ago.
Which finding is most critical for the nurse to report to the healthcare provider?
Answer: Global confusion and inability to recognize family members.
5. A male client who is on the liver transplant list is called to the unit for a possible
transplant.When learning that the donor organ is no longer available,the client slams doors and
shouts vulgarities about his situation. What actionshould the nurse implement?
Answer: Express concern over his disappointment.
6. The nurse is caring for a female client who is admitted for depression with the nursing
diagnosis, "Self-esteem, chronic low." Which client responseindicates to the nurse that the client
has improved self-esteem?
Answer: Identifies ownstrengths
7. A client with panic disorder tells the nurse, "This illness is awful. I'm frightened that I will
always be this way and that there's no hope for me." Whatinformation should the nurse provide?
Answer: Panic disorder is treatable in a number of different ways, including medication.
8. Which client outcome during hospitalization indicates improvement for a client who is
admitted with auditory hallucinations?
Answer: Tells when voices de-crease.
, 9. Which action is most important for the nurse to implement during the initial interview for
a client who is admitted to the mental health unit?
Answer: Establishrapport in each phase of the nurse-client relationship.
10. Which statement made by an adolescent in group therapy should the nurse identify as a
priority in planning care?
Answer: I have a necktie in my room that I can useto hang myself.
11. A male client tells the nurse that he plans to kill his spouse and her loveras soon as he is
released from the hospital. What action should the nurse implement?
Answer: Inform the healthcare provider and document the plan in the record.
12. Which client statement should the nurse identify as most typical of a clientwith mania?
Answer: I manage our finances great because I buy in big quantities.
13. A client is pacing in the hall near the nurses' station and swearing loudly. What response is
best for the nurse to provide?
Answer: You seem pretty upset. Tell meabout it.
14. A client actively involved in substance addiction therapy frequently relapses into
benzodiazepines and alcohol use. The client tells the nurse, "I don't think I will ever be able to
kick this habit." How should the nurse respond?
Answer: Theclient must participate in making decisions about one's own physical and mental
health.
15. Which action should the nurse implement during the termination phase ofthe nurse-client
relationship?
Answer: Help summarize accomplishments.
16. A school-aged girl with severe birth defects and mental retardation is brought to the
emergency room because of a possible broken arm.The care-giver reports that the girl
sustained the injury when she fell from her wheel- chair. Which intervention should the nurse
implement?
Answer: Evaluate the child for other injuries.
17. A client who is intoxicated is admitted for alcohol and multiple substancedetoxification.
The nurse determines that the client is becoming increasinglyanxious, agitated, and
diaphoretic. The client is also experiencing sensory perceptual disturbances and a clouded
sensorium.What is the priority nursingintervention for this client at this time?
Answer: Begin one-on-one supervision immediately.
18. What nursing assessment is the priority focus for a client with majordepression?
Answer: Suicidal ideation.
1. A client with substance abuse is admitted to the mental health unit. Whichaction should be
implemented by the nurse, and not delegated to a unlicensedassistive personnel (UAP)?
Answer: Collect a complete substance abuse history.
2. A female client with bipolar disorder, manic phase, is planning weekend activities with
the other clients on the unit. The client interrupts the group, insists that they change their plans
to a disco party, and begins to curse loudlywhen the group refuses to change the plans. Which
intervention should the nurse implement?
Answer: Escort the client to a quieter place
3. A client with a history of alcoholism is admitted with a compound fractureof the femur
after falling down the previous night.What additional assessmentshould be the priority focus
for the nurse?
Answer: Ask the client about the quantity, frequency, and time the last alcohol drink was
ingested.
4. The nurse is caring for a client who was admitted for alcohol detoxification2 days ago.
Which finding is most critical for the nurse to report to the healthcare provider?
Answer: Global confusion and inability to recognize family members.
5. A male client who is on the liver transplant list is called to the unit for a possible
transplant.When learning that the donor organ is no longer available,the client slams doors and
shouts vulgarities about his situation. What actionshould the nurse implement?
Answer: Express concern over his disappointment.
6. The nurse is caring for a female client who is admitted for depression with the nursing
diagnosis, "Self-esteem, chronic low." Which client responseindicates to the nurse that the client
has improved self-esteem?
Answer: Identifies ownstrengths
7. A client with panic disorder tells the nurse, "This illness is awful. I'm frightened that I will
always be this way and that there's no hope for me." Whatinformation should the nurse provide?
Answer: Panic disorder is treatable in a number of different ways, including medication.
8. Which client outcome during hospitalization indicates improvement for a client who is
admitted with auditory hallucinations?
Answer: Tells when voices de-crease.
, 9. Which action is most important for the nurse to implement during the initial interview for
a client who is admitted to the mental health unit?
Answer: Establishrapport in each phase of the nurse-client relationship.
10. Which statement made by an adolescent in group therapy should the nurse identify as a
priority in planning care?
Answer: I have a necktie in my room that I can useto hang myself.
11. A male client tells the nurse that he plans to kill his spouse and her loveras soon as he is
released from the hospital. What action should the nurse implement?
Answer: Inform the healthcare provider and document the plan in the record.
12. Which client statement should the nurse identify as most typical of a clientwith mania?
Answer: I manage our finances great because I buy in big quantities.
13. A client is pacing in the hall near the nurses' station and swearing loudly. What response is
best for the nurse to provide?
Answer: You seem pretty upset. Tell meabout it.
14. A client actively involved in substance addiction therapy frequently relapses into
benzodiazepines and alcohol use. The client tells the nurse, "I don't think I will ever be able to
kick this habit." How should the nurse respond?
Answer: Theclient must participate in making decisions about one's own physical and mental
health.
15. Which action should the nurse implement during the termination phase ofthe nurse-client
relationship?
Answer: Help summarize accomplishments.
16. A school-aged girl with severe birth defects and mental retardation is brought to the
emergency room because of a possible broken arm.The care-giver reports that the girl
sustained the injury when she fell from her wheel- chair. Which intervention should the nurse
implement?
Answer: Evaluate the child for other injuries.
17. A client who is intoxicated is admitted for alcohol and multiple substancedetoxification.
The nurse determines that the client is becoming increasinglyanxious, agitated, and
diaphoretic. The client is also experiencing sensory perceptual disturbances and a clouded
sensorium.What is the priority nursingintervention for this client at this time?
Answer: Begin one-on-one supervision immediately.
18. What nursing assessment is the priority focus for a client with majordepression?
Answer: Suicidal ideation.
