PSYCH/MENTAL HEALTH EXIT HESI – SAUNDERS
The nurse in the mental health unit is assigned to care for a female client with a
diagnosis of acute depression. In communicating with the client, which statement would
be appropriate for the nurse to make?
1. "You look lovely today."
2. "You're wearing a new blouse."
3. "Don't worry-everyone gets depressed once in a while."
4. "You will feel better when your medication starts to work." - Answers :2. "You're
wearing a new blouse."
Rationale:
A client who is depressed sees the negative side of everything. Telling the client that
she looks lovely today can be interpreted as "didn't look lovely last time we met."
Neutral comments such as that identified in the correct option will avoid negative
interpretations. The client should not be told not to worry, that everyone gets depressed
once in a while, or that he or she will feel better, because such statements are
inappropriate.
The nurse is planning care for a client with bipolar disorder who is experiencing
psychomotor agitation. Which activity should the nurse plan for this client?
1. Reading letters and books in a quiet environment
2. Providing an activity such as checkers for the client
3. Involving the client in a card game with other clients on the unit
4. Including the client in a clay-molding class that is scheduled for today - Answers :4.
Including the client in a clay-molding class that is scheduled for today
Rationale:
When a client is experiencing psychomotor agitation, it is best to provide activities that
involve the use of hands and gross motor movements. Such activities can include
volleyball, finger-painting, drawing, and working with clay. These activities provide an
appropriate way for the client to discharge motor tension. Reading and simple card
games are sedentary activities. Playing checkers requires concentration and more
intensive use of thought processes.
The nurse is developing a plan of care for a client with depression whose food intake is
poor. The nurse should include which interventions in the plan of care? Select all that
apply.
1. Assist the client in selecting foods from the food menu.
2. Offer high-calorie fluids throughout the day and evening.
3. Allow the client to eat alone in the room if the client requests to do so.
4. Offer small high-calorie, high-protein snacks during the day and evening.
,5. Select the foods for the client to be sure that the client eats a balanced diet. -
Answers :1, 2, 4
Rationale:
In caring for a client with depression whose nutritional intake is poor, the nurse should
remain with the client during the meal. The nurse also should assist the client in
selecting foods from the menu because the client is more likely to eat the foods that he
or she likes. Offering small high-calorie, high-protein snacks and high-calorie fluids
throughout the day and evening are appropriate interventions for the client to maintain
nutrition.
On review of the client's record, the nurse notes that the mental health admission was
voluntary. Based on this information, the nurse anticipates which client behavior?
1. Fearfulness regarding treatment measures.
2. Anger and aggressiveness directed toward others.
3. An understanding of the pathology and symptoms of the diagnosis.
4. A willingness to participate in the planning of the care and treatment plan. - Answers
:4. A willingness to participate in the planning of the care and treatment plan.
Rationale:
In general, clients seek voluntary admission. If a client seeks voluntary admission, the
most likely expectation is that the client will participate in the treatment program since
they are actively seeking help. The remaining options are not characteristics of this type
of admission. Fearfulness, anger, and aggressiveness are more characteristic of an
involuntary admission. Voluntary admission does not guarantee a client's understanding
of their illness, only of their desire for help.
When reviewing the admission assessment, the nurse notes that a client was admitted
to the mental health unit involuntarily. Based on this type of admission, the nurse should
provide which intervention for this client?
1. Monitor closely for harm to self or others.
2. Assist in completing an application for admission.
3. Supply the client with written information about their mental illness.
4. Provide an opportunity for the family to discuss why they felt the admission was
needed. - Answers :1. Monitor closely for harm to self or others.
Rationale:
Involuntary admission is necessary when a person is a danger to self or others or is in
need of psychiatric treatment regardless of the client's willingness to consent to the
hospitalization. A written request is a component of a voluntary admission. Providing
written information regarding the illness is likely premature initially. The family may have
had no role to play in the client's admission.
,The nurse is preparing a client for the termination phase of the nurse-client relationship.
The nurse prepares to implement which nursing task that is most appropriate for this
phase?
1. Planning short-term goals
2. Making appointment referrals
3. Developing realistic solutions
4. Identifying expected outcomes - Answers :2. Making appointment referrals
Rationale:
Tasks of the termination phase include evaluating client performance, evaluating
achievement of expected outcomes, evaluating future needs, making appropriate
referrals, and dealing with the common behaviors associated with termination. The
remaining options identify tasks appropriate for the working phase of the relationship.
The nurse in the mental health unit recognizes which as being therapeutic
communication techniques? Select all that apply.
1. Restating
2. Listening
3. Asking the client, "Why?"
4. Maintaining neutral responses
5. Providing acknowledgment and feedback
6. Giving advice and approval or disapproval - Answers :1, 2, 4, 5
Rationale:
Therapeutic communication techniques include listening, maintaining silence,
maintaining neutral responses, using broad openings and open-ended questions,
focusing and refocusing, restating, clarifying and validating, sharing perceptions,
reflecting, providing acknowledgment and feedback, giving information, presenting
reality, encouraging formulation of a plan of action, providing nonverbal encouragement,
and summarizing. Asking why is often interpreted as being accusatory by the client and
should also be avoided. Providing advice or giving approval or disapproval are barriers
to communication.
A client with a diagnosis of major depression who has attempted suicide says to the
nurse, "I should have died. I've always been a failure. Nothing ever goes right for me."
Which response demonstrates therapeutic communication?
1. "You have everything to live for."
2. "Why do you see yourself as a failure?"
3. "Feeling like this is all part of being depressed."
4. "You've been feeling like a failure for a while?" - Answers :4. "You've been feeling like
a failure for a while?"
Rationale:
, Responding to the feelings expressed by a client is an effective therapeutic
communication technique. The correct option is an example of the use of restating. The
remaining options block communication because they minimize the client's experience
and do not facilitate exploration of the client's expressed feelings. In addition, use of the
word "why" is nontherapeutic.
When the mental health nurse visits a client at home, the client states, "I haven't slept at
all the last couple of nights." Which response by the nurse illustrates a therapeutic
communication response to this client?
1. "I see."
2. "Really?"
3. "You're having difficulty sleeping?"
4. "Sometimes, I have trouble sleeping too." - Answers :3. "You're having difficulty
sleeping?"
Rationale:
The correct option uses the therapeutic communication technique of restatement.
Although restatement is a technique that has a prompting component to it, it repeats the
client's major theme, which assists the nurse to obtain a more specific perception of the
problem from the client. The remaining options are not therapeutic responses since
none encourage the client to expand on the problem. Offering personal experiences
moves the focus away from the client and onto the nurse.
A client experiencing disturbed thought processes believes that his food is being
poisoned. Which communication technique should the nurse use to encourage the client
to eat?
1. Using open-ended questions and silence
2. Sharing personal preference regarding food choices
3. Documenting reasons why the client does not want to eat
4. Offering opinions about the necessity of adequate nutrition - Answers :1. Using open-
ended questions and silence
Rationale:
Open-ended questions and silence are strategies used to encourage clients to discuss
their problems. Sharing personal food preferences is not a client-centered intervention.
The remaining options are not helpful to the client because they do not encourage the
client to express feelings. The nurse should not offer opinions and should encourage
the client to identify the reasons for the behavior.
A client admitted to a mental health unit for treatment of psychotic behavior spends
hours at the locked exit door shouting, "Let me out. There's nothing wrong with me. I
don't belong here." What defense mechanism is the client implementing?
1. Denial
The nurse in the mental health unit is assigned to care for a female client with a
diagnosis of acute depression. In communicating with the client, which statement would
be appropriate for the nurse to make?
1. "You look lovely today."
2. "You're wearing a new blouse."
3. "Don't worry-everyone gets depressed once in a while."
4. "You will feel better when your medication starts to work." - Answers :2. "You're
wearing a new blouse."
Rationale:
A client who is depressed sees the negative side of everything. Telling the client that
she looks lovely today can be interpreted as "didn't look lovely last time we met."
Neutral comments such as that identified in the correct option will avoid negative
interpretations. The client should not be told not to worry, that everyone gets depressed
once in a while, or that he or she will feel better, because such statements are
inappropriate.
The nurse is planning care for a client with bipolar disorder who is experiencing
psychomotor agitation. Which activity should the nurse plan for this client?
1. Reading letters and books in a quiet environment
2. Providing an activity such as checkers for the client
3. Involving the client in a card game with other clients on the unit
4. Including the client in a clay-molding class that is scheduled for today - Answers :4.
Including the client in a clay-molding class that is scheduled for today
Rationale:
When a client is experiencing psychomotor agitation, it is best to provide activities that
involve the use of hands and gross motor movements. Such activities can include
volleyball, finger-painting, drawing, and working with clay. These activities provide an
appropriate way for the client to discharge motor tension. Reading and simple card
games are sedentary activities. Playing checkers requires concentration and more
intensive use of thought processes.
The nurse is developing a plan of care for a client with depression whose food intake is
poor. The nurse should include which interventions in the plan of care? Select all that
apply.
1. Assist the client in selecting foods from the food menu.
2. Offer high-calorie fluids throughout the day and evening.
3. Allow the client to eat alone in the room if the client requests to do so.
4. Offer small high-calorie, high-protein snacks during the day and evening.
,5. Select the foods for the client to be sure that the client eats a balanced diet. -
Answers :1, 2, 4
Rationale:
In caring for a client with depression whose nutritional intake is poor, the nurse should
remain with the client during the meal. The nurse also should assist the client in
selecting foods from the menu because the client is more likely to eat the foods that he
or she likes. Offering small high-calorie, high-protein snacks and high-calorie fluids
throughout the day and evening are appropriate interventions for the client to maintain
nutrition.
On review of the client's record, the nurse notes that the mental health admission was
voluntary. Based on this information, the nurse anticipates which client behavior?
1. Fearfulness regarding treatment measures.
2. Anger and aggressiveness directed toward others.
3. An understanding of the pathology and symptoms of the diagnosis.
4. A willingness to participate in the planning of the care and treatment plan. - Answers
:4. A willingness to participate in the planning of the care and treatment plan.
Rationale:
In general, clients seek voluntary admission. If a client seeks voluntary admission, the
most likely expectation is that the client will participate in the treatment program since
they are actively seeking help. The remaining options are not characteristics of this type
of admission. Fearfulness, anger, and aggressiveness are more characteristic of an
involuntary admission. Voluntary admission does not guarantee a client's understanding
of their illness, only of their desire for help.
When reviewing the admission assessment, the nurse notes that a client was admitted
to the mental health unit involuntarily. Based on this type of admission, the nurse should
provide which intervention for this client?
1. Monitor closely for harm to self or others.
2. Assist in completing an application for admission.
3. Supply the client with written information about their mental illness.
4. Provide an opportunity for the family to discuss why they felt the admission was
needed. - Answers :1. Monitor closely for harm to self or others.
Rationale:
Involuntary admission is necessary when a person is a danger to self or others or is in
need of psychiatric treatment regardless of the client's willingness to consent to the
hospitalization. A written request is a component of a voluntary admission. Providing
written information regarding the illness is likely premature initially. The family may have
had no role to play in the client's admission.
,The nurse is preparing a client for the termination phase of the nurse-client relationship.
The nurse prepares to implement which nursing task that is most appropriate for this
phase?
1. Planning short-term goals
2. Making appointment referrals
3. Developing realistic solutions
4. Identifying expected outcomes - Answers :2. Making appointment referrals
Rationale:
Tasks of the termination phase include evaluating client performance, evaluating
achievement of expected outcomes, evaluating future needs, making appropriate
referrals, and dealing with the common behaviors associated with termination. The
remaining options identify tasks appropriate for the working phase of the relationship.
The nurse in the mental health unit recognizes which as being therapeutic
communication techniques? Select all that apply.
1. Restating
2. Listening
3. Asking the client, "Why?"
4. Maintaining neutral responses
5. Providing acknowledgment and feedback
6. Giving advice and approval or disapproval - Answers :1, 2, 4, 5
Rationale:
Therapeutic communication techniques include listening, maintaining silence,
maintaining neutral responses, using broad openings and open-ended questions,
focusing and refocusing, restating, clarifying and validating, sharing perceptions,
reflecting, providing acknowledgment and feedback, giving information, presenting
reality, encouraging formulation of a plan of action, providing nonverbal encouragement,
and summarizing. Asking why is often interpreted as being accusatory by the client and
should also be avoided. Providing advice or giving approval or disapproval are barriers
to communication.
A client with a diagnosis of major depression who has attempted suicide says to the
nurse, "I should have died. I've always been a failure. Nothing ever goes right for me."
Which response demonstrates therapeutic communication?
1. "You have everything to live for."
2. "Why do you see yourself as a failure?"
3. "Feeling like this is all part of being depressed."
4. "You've been feeling like a failure for a while?" - Answers :4. "You've been feeling like
a failure for a while?"
Rationale:
, Responding to the feelings expressed by a client is an effective therapeutic
communication technique. The correct option is an example of the use of restating. The
remaining options block communication because they minimize the client's experience
and do not facilitate exploration of the client's expressed feelings. In addition, use of the
word "why" is nontherapeutic.
When the mental health nurse visits a client at home, the client states, "I haven't slept at
all the last couple of nights." Which response by the nurse illustrates a therapeutic
communication response to this client?
1. "I see."
2. "Really?"
3. "You're having difficulty sleeping?"
4. "Sometimes, I have trouble sleeping too." - Answers :3. "You're having difficulty
sleeping?"
Rationale:
The correct option uses the therapeutic communication technique of restatement.
Although restatement is a technique that has a prompting component to it, it repeats the
client's major theme, which assists the nurse to obtain a more specific perception of the
problem from the client. The remaining options are not therapeutic responses since
none encourage the client to expand on the problem. Offering personal experiences
moves the focus away from the client and onto the nurse.
A client experiencing disturbed thought processes believes that his food is being
poisoned. Which communication technique should the nurse use to encourage the client
to eat?
1. Using open-ended questions and silence
2. Sharing personal preference regarding food choices
3. Documenting reasons why the client does not want to eat
4. Offering opinions about the necessity of adequate nutrition - Answers :1. Using open-
ended questions and silence
Rationale:
Open-ended questions and silence are strategies used to encourage clients to discuss
their problems. Sharing personal food preferences is not a client-centered intervention.
The remaining options are not helpful to the client because they do not encourage the
client to express feelings. The nurse should not offer opinions and should encourage
the client to identify the reasons for the behavior.
A client admitted to a mental health unit for treatment of psychotic behavior spends
hours at the locked exit door shouting, "Let me out. There's nothing wrong with me. I
don't belong here." What defense mechanism is the client implementing?
1. Denial
