HESI Module 3
The mother of a 3-year-old child tells the nurse that her child hit her doll after the mother
scolded her for picking the neighbors' flowers. Which defense mechanism used by the child
does the nurse identify in the mother's report?
- Projection
- Sublimation
- Displacement
- Identification - ANS displacement
A client says to the nurse, "I've been following my diet and taking my medication. What else do
you want to talk about today?" Which response would be most helpful during the working phase
of the therapeutic alliance?
- "Sounds fine to me. Let's meet again in 6 months."
- "I don't believe that you have been following your diet, because you haven't lost any weight."
- "Well, you've talked about diet in your terms, but perhaps I should test you on specific things."
"Some people have added exercise to diet and medication therapy and gotten positive results.
Do you think that this would work for you?" - ANS Some people have added exercise to diet
and medication therapy and gotten positive results. Do you think that this would work for you
As the nurse prepares to interview a client being admitted to the mental health unit, the client
says, "I asked my family to bring me in here to talk to someone, but now I don't know where to
begin." Which response by the nurse would be most helpful?
- "Why not just start talking and see where it takes you?"
- "If I were you, I'd begin with what you were doing this morning."
- "Perhaps you can start by sharing some of your most recent concerns."
- "Don't worry. Everyone who comes in here for the first time feels reluctant to talk." - ANS
Perhaps you can start by sharing some of your most recent concerns
During a mental health intake interview, a young adult client who lives with his family rent free
says, "I'm tired of not being able to offer my friends a beer just because my folks don't believe in
taking a drink socially." Which nursing response would be therapeutic?
- "Well, I guess you could move out and live on your own if you wanted to."
- "It seems that your parents expect you to follow their rules when you live under their roof."
- "You tell me you live rent free, yet you expect the same privileges as an adult who supports the
household?"
- "Well, if you directly discussed your concerns with them, I guess it's a case of 'When in Rome,
do as the Romans do.'" - ANS It seems that your parents expect you to follow their rules when
you live under their roof
,The nurse developing a plan of care for a client whose spouse recently died, determines the
client has a problem with dysfunctional grieving. Which priority intervention does the nurse
incorporate into the plan?
- Monitoring the client's sleep pattern
- Assessing the client's risk for violence toward self and others
- Obtaining a health care provider's prescription for an antidepressant
Assisting the client in resolving the grief through emotional, cognitive, and behavioral means -
ANS Assessing the client's risk for violence toward self and others
A client in the mental health unit tells the nurse, "My husband makes all the decisions about
money, but I'm the one who's making the money now, not him. He needs to back off, but he's
always directing every decision we make." Which nursing response would be the most
therapeutic?
- "Have you told your husband to back off"?
- "You're making the most money, so the decisions should be left to you."
- "How do you feel the money decisions could best be handled in your household?"
- "You seem frustrated with your husband's habit of controlling financial decisions." - ANS How
do you feel the money decisions could best be handled in your household
The new nurse employee is developing a plan of care, with the registered nurse, for a client who
recently received a diagnosis of acquired immunodeficiency syndrome (AIDS) and is
experiencing difficulty adjusting to the illness. The registered nurse should suggest revision of
which intervention for this client?
- Monitoring the client for signs of self-harm
- Helping the client verbalize concerns related to fear Incorrect
- Assisting the client with problem-solving and decision-making
- Discouraging social networking to prevent the spread of infection - ANS Discouraging social
networking to prevent the spread of infection
A nurse is caring for a patient whose spouse has died. How does the nurse determine that a
client who has lost a spouse has successfully completed the tasks of mourning? Select all that
apply.
A. Relating that "its better he went first"
B. Reporting that sleeping alone is so hard now
C. Purchasing a smaller car she is comfortable driving
D. Placing a picture of her husband on the bedside stand
E. Heard explaining to family that illness "took" her husband - ANS B, C, D, E
The nurse is caring for a 15-year-old girl who has been hospitalized. The client tells the nurse
that she had her hair styled just like her young math teacher, whom she admires. Which
defense mechanism should the nurse recognize that the client is using?
- Projection
- Regression
- Identification
, - Intellectualization - ANS Identification
The mental health home care nurse says to the client, "Do you feel ready to try attending a
group session at the clinic?" The client shakes his head. Which nursing statement would be
therapeutic?
- "No? Why not?"
- "You seem to be saying no. Would you tell me more about your reluctance?"
- "OK, but I hope you will let me know when you feel ready to attend a group session at the
clinic."
- "Perhaps a group session would be too overwhelming for you right now. How about just seeing
me?" - ANS You seem to be saying no. Would you tell me more about your reluctance
A single mother whose son was suspended from school for carrying a gun into the school, says
to the nurse, "I know he has no dad, but I've brought him up to know better, and anyway, where
did he get the stupid gun? What should I do? He just won't listen to me." Which nursing
response would be helpful at this time?
- "Boys who are cared for only by their moms are at highest risk for violent behavior."
- "There is quite a bit that you can do. Let's talk about what you're already doing first."
- "Do you know all of your son's friends, or is he left alone after school because you work?"
- "Many young people die of gunshots every day in this country, so your son's behavior is
unacceptable." - ANS There is quite a bit that you can do. Let's talk about what you're already
doing first
A client says to the nurse, "My doctor says he thinks I'm ready to taper off my pain medication,
but the new painkiller he prescribed doesn't relieve my pain the way the other pill did. I get pain
when I try to do things." Which nursing response would be most supportive to the client?
-"Your health care provider feels that your body is physically ready to make the change in
medication."
- "I think you need to listen to your health care provider when it comes to taking such strong
medication."
- "Well, your health care provider is concerned that you will become physically dependent on the
first painkiller."
- "Perhaps if I medicate you about a half-hour before you plan to start your daily activities, the
medicine will be more effective." - ANS Perhaps if I medicate you about a half-hour before you
plan to start your daily activities, the medicine will be more effective.
A client who was employed as a corporate manager before being laid off says to the nurse, "My
wife thinks that I should work in a menial job to maintain our lifestyles until I find another job as a
corporate manager, but I don't feel I should have to humiliate myself like that." Which nursing
response would be therapeutic?
- "Have you shared your feelings with your wife?"
- "You seem to feel that a less prestigious job would be humiliating for you."
- "Oh, I agree with you. Let her get another job if she needs that much money."
The mother of a 3-year-old child tells the nurse that her child hit her doll after the mother
scolded her for picking the neighbors' flowers. Which defense mechanism used by the child
does the nurse identify in the mother's report?
- Projection
- Sublimation
- Displacement
- Identification - ANS displacement
A client says to the nurse, "I've been following my diet and taking my medication. What else do
you want to talk about today?" Which response would be most helpful during the working phase
of the therapeutic alliance?
- "Sounds fine to me. Let's meet again in 6 months."
- "I don't believe that you have been following your diet, because you haven't lost any weight."
- "Well, you've talked about diet in your terms, but perhaps I should test you on specific things."
"Some people have added exercise to diet and medication therapy and gotten positive results.
Do you think that this would work for you?" - ANS Some people have added exercise to diet
and medication therapy and gotten positive results. Do you think that this would work for you
As the nurse prepares to interview a client being admitted to the mental health unit, the client
says, "I asked my family to bring me in here to talk to someone, but now I don't know where to
begin." Which response by the nurse would be most helpful?
- "Why not just start talking and see where it takes you?"
- "If I were you, I'd begin with what you were doing this morning."
- "Perhaps you can start by sharing some of your most recent concerns."
- "Don't worry. Everyone who comes in here for the first time feels reluctant to talk." - ANS
Perhaps you can start by sharing some of your most recent concerns
During a mental health intake interview, a young adult client who lives with his family rent free
says, "I'm tired of not being able to offer my friends a beer just because my folks don't believe in
taking a drink socially." Which nursing response would be therapeutic?
- "Well, I guess you could move out and live on your own if you wanted to."
- "It seems that your parents expect you to follow their rules when you live under their roof."
- "You tell me you live rent free, yet you expect the same privileges as an adult who supports the
household?"
- "Well, if you directly discussed your concerns with them, I guess it's a case of 'When in Rome,
do as the Romans do.'" - ANS It seems that your parents expect you to follow their rules when
you live under their roof
,The nurse developing a plan of care for a client whose spouse recently died, determines the
client has a problem with dysfunctional grieving. Which priority intervention does the nurse
incorporate into the plan?
- Monitoring the client's sleep pattern
- Assessing the client's risk for violence toward self and others
- Obtaining a health care provider's prescription for an antidepressant
Assisting the client in resolving the grief through emotional, cognitive, and behavioral means -
ANS Assessing the client's risk for violence toward self and others
A client in the mental health unit tells the nurse, "My husband makes all the decisions about
money, but I'm the one who's making the money now, not him. He needs to back off, but he's
always directing every decision we make." Which nursing response would be the most
therapeutic?
- "Have you told your husband to back off"?
- "You're making the most money, so the decisions should be left to you."
- "How do you feel the money decisions could best be handled in your household?"
- "You seem frustrated with your husband's habit of controlling financial decisions." - ANS How
do you feel the money decisions could best be handled in your household
The new nurse employee is developing a plan of care, with the registered nurse, for a client who
recently received a diagnosis of acquired immunodeficiency syndrome (AIDS) and is
experiencing difficulty adjusting to the illness. The registered nurse should suggest revision of
which intervention for this client?
- Monitoring the client for signs of self-harm
- Helping the client verbalize concerns related to fear Incorrect
- Assisting the client with problem-solving and decision-making
- Discouraging social networking to prevent the spread of infection - ANS Discouraging social
networking to prevent the spread of infection
A nurse is caring for a patient whose spouse has died. How does the nurse determine that a
client who has lost a spouse has successfully completed the tasks of mourning? Select all that
apply.
A. Relating that "its better he went first"
B. Reporting that sleeping alone is so hard now
C. Purchasing a smaller car she is comfortable driving
D. Placing a picture of her husband on the bedside stand
E. Heard explaining to family that illness "took" her husband - ANS B, C, D, E
The nurse is caring for a 15-year-old girl who has been hospitalized. The client tells the nurse
that she had her hair styled just like her young math teacher, whom she admires. Which
defense mechanism should the nurse recognize that the client is using?
- Projection
- Regression
- Identification
, - Intellectualization - ANS Identification
The mental health home care nurse says to the client, "Do you feel ready to try attending a
group session at the clinic?" The client shakes his head. Which nursing statement would be
therapeutic?
- "No? Why not?"
- "You seem to be saying no. Would you tell me more about your reluctance?"
- "OK, but I hope you will let me know when you feel ready to attend a group session at the
clinic."
- "Perhaps a group session would be too overwhelming for you right now. How about just seeing
me?" - ANS You seem to be saying no. Would you tell me more about your reluctance
A single mother whose son was suspended from school for carrying a gun into the school, says
to the nurse, "I know he has no dad, but I've brought him up to know better, and anyway, where
did he get the stupid gun? What should I do? He just won't listen to me." Which nursing
response would be helpful at this time?
- "Boys who are cared for only by their moms are at highest risk for violent behavior."
- "There is quite a bit that you can do. Let's talk about what you're already doing first."
- "Do you know all of your son's friends, or is he left alone after school because you work?"
- "Many young people die of gunshots every day in this country, so your son's behavior is
unacceptable." - ANS There is quite a bit that you can do. Let's talk about what you're already
doing first
A client says to the nurse, "My doctor says he thinks I'm ready to taper off my pain medication,
but the new painkiller he prescribed doesn't relieve my pain the way the other pill did. I get pain
when I try to do things." Which nursing response would be most supportive to the client?
-"Your health care provider feels that your body is physically ready to make the change in
medication."
- "I think you need to listen to your health care provider when it comes to taking such strong
medication."
- "Well, your health care provider is concerned that you will become physically dependent on the
first painkiller."
- "Perhaps if I medicate you about a half-hour before you plan to start your daily activities, the
medicine will be more effective." - ANS Perhaps if I medicate you about a half-hour before you
plan to start your daily activities, the medicine will be more effective.
A client who was employed as a corporate manager before being laid off says to the nurse, "My
wife thinks that I should work in a menial job to maintain our lifestyles until I find another job as a
corporate manager, but I don't feel I should have to humiliate myself like that." Which nursing
response would be therapeutic?
- "Have you shared your feelings with your wife?"
- "You seem to feel that a less prestigious job would be humiliating for you."
- "Oh, I agree with you. Let her get another job if she needs that much money."
