1
(NGN) HESI MENTAL HEALTH RN V1-V3 TEST BANK
QUESTIONS WITH CORRECT ANSWERS
Pepperoni pizza. - ANSWER--A client with Bulimia and depression who is taking
phenelzine (Nardil) 90 mg daily is admitted to an acute care hospital for
uncontrolled hypertension. What dietary choices should the RN instruct the client
to avoid?
Is attempting the physically restrain the patient. - ANSWER--A mental health
worker is caring for a client with escalating aggressive behavior. Which action by
the mental health worker warrants immediate intervention by the RN?
Not sleeping for several days. - ANSWER--A client who recently experienced the
death of a significant other arrives at the mental health center. The client reports
loss of interest in usual activities, expresses a wish to be with the decreased
significant other, has been eating very little, and has not slept in several days.
Which client statement is most important for the RN to explore at this time?
Teach the client to develop a plan for daily structured activities. - ANSWER--A
middle aged adult with major depressive disorder suffers from psychomotor
retardation, hypersomnia, and motivation. Which intervention is likely to be most
effective in returning this client to a normal level of functioning?
Ineffective breathing pattern. - ANSWER--When developing a plan of care for a
client admitted to the psychiatric unit following aspiration of a caustic material
related to a suicide attempt, which nursing problem has the highest priority?
Risk for other related violence related to disruptive behavior. - ANSWER--A female
client on a psychiatric unit is sweating profusely while she vigorously does push-
ups and then runs the length of the corridor several times before crashing into
furniture in the sitting room. Picking herself up, she begins to toss chairs aside,
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looking for a red one to sit in. When another client objects to the disturbance, the
client shouts, "I am the boss here. I do what I want." Which nursing problem best
supports these observations?
Reduce the noise level in the room by turning off the television and radio. -
ANSWER--A RN is preparing the physical environment to interview a new client
for admission to the mental health unit. Which environmental setting facilitates
the best outcome of the interview?
Determine if Xanax was taken recently. - ANSWER--An older homeless client visits
the psychiatric clinic to obtain a prescription renewal for alprazolam (Xanax).
During the health assessment, the client complains of chest pain. Which action
should the RN take first?
Infection control. - ANSWER--Several clients with chronic mental illness and
multiple substance abuse histories live in a group residential home and attend
daycare mental health facility where group and individual therapies are provided.
The RN finds the common bathroom at the facility with sputum on the walls,
urine in the sink and on the floors, and the toilet stopped up with tissue, paper
towels, and feces. What is the priority issue that the RN should address?
Provide the client with food in unopened containers. - ANSWER--A client with
schizophrenia is admitted to the psychiatric care unit for aggressive behavior,
auditory hallucinations, and potential for safe harm. The client has not been
taking medications as prescribed and insists that the food has been poisoned and
refuses to eat. What intervention should the RN implement?
Establish a code with family and friends to signify violence.
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Have a bag ready that has extra clothes for self and children.
Plan an escape route to use if the abuser blocks the main exit. - ANSWER--The RN
is providing education about strategies for a safety plan for a female client who is
a victim of intimate partner violence. Which strategies should be included in the
safety plan? (SOA)
Nausea and vomiting. - ANSWER--The RN is admitting a male client who take
lithium carbonate (Eskalith) twice a day. Which information should the RN report
to the HCP immediately?
Monitor vital signs. - ANSWER--A male client who is admitted with delirium
tremens is dehydrated and experiencing auditory hallucinations. He has a bruised,
swollen tongue and is confused. In developing a plan of care, which action should
the RN include to ensure the client is physiologically stable?
Assign the UAP to remain with the client at all times. - ANSWER--The RN is
working with a male client at a community mental health center when the client
reports hearing voices that tell him to get a knife from the kitchen and hurt
himself. What intervention is most important for the RN to implement?
Allow the client to rest and sleep. - ANSWER--A homeless client who reports
feeling sad and depressed tells the mental health nurse that in the past 2 days she
has only had 4 hours of sleep. Which action is most important for the RN to
implement within the first 24 hours after treatment is initiated?
I am here because the police thought I was doing something wrong. - ANSWER--
Which client statement suggests the RN that the client is using a defense
(NGN) HESI MENTAL HEALTH RN V1-V3 TEST BANK
QUESTIONS WITH CORRECT ANSWERS
Pepperoni pizza. - ANSWER--A client with Bulimia and depression who is taking
phenelzine (Nardil) 90 mg daily is admitted to an acute care hospital for
uncontrolled hypertension. What dietary choices should the RN instruct the client
to avoid?
Is attempting the physically restrain the patient. - ANSWER--A mental health
worker is caring for a client with escalating aggressive behavior. Which action by
the mental health worker warrants immediate intervention by the RN?
Not sleeping for several days. - ANSWER--A client who recently experienced the
death of a significant other arrives at the mental health center. The client reports
loss of interest in usual activities, expresses a wish to be with the decreased
significant other, has been eating very little, and has not slept in several days.
Which client statement is most important for the RN to explore at this time?
Teach the client to develop a plan for daily structured activities. - ANSWER--A
middle aged adult with major depressive disorder suffers from psychomotor
retardation, hypersomnia, and motivation. Which intervention is likely to be most
effective in returning this client to a normal level of functioning?
Ineffective breathing pattern. - ANSWER--When developing a plan of care for a
client admitted to the psychiatric unit following aspiration of a caustic material
related to a suicide attempt, which nursing problem has the highest priority?
Risk for other related violence related to disruptive behavior. - ANSWER--A female
client on a psychiatric unit is sweating profusely while she vigorously does push-
ups and then runs the length of the corridor several times before crashing into
furniture in the sitting room. Picking herself up, she begins to toss chairs aside,
, 2
looking for a red one to sit in. When another client objects to the disturbance, the
client shouts, "I am the boss here. I do what I want." Which nursing problem best
supports these observations?
Reduce the noise level in the room by turning off the television and radio. -
ANSWER--A RN is preparing the physical environment to interview a new client
for admission to the mental health unit. Which environmental setting facilitates
the best outcome of the interview?
Determine if Xanax was taken recently. - ANSWER--An older homeless client visits
the psychiatric clinic to obtain a prescription renewal for alprazolam (Xanax).
During the health assessment, the client complains of chest pain. Which action
should the RN take first?
Infection control. - ANSWER--Several clients with chronic mental illness and
multiple substance abuse histories live in a group residential home and attend
daycare mental health facility where group and individual therapies are provided.
The RN finds the common bathroom at the facility with sputum on the walls,
urine in the sink and on the floors, and the toilet stopped up with tissue, paper
towels, and feces. What is the priority issue that the RN should address?
Provide the client with food in unopened containers. - ANSWER--A client with
schizophrenia is admitted to the psychiatric care unit for aggressive behavior,
auditory hallucinations, and potential for safe harm. The client has not been
taking medications as prescribed and insists that the food has been poisoned and
refuses to eat. What intervention should the RN implement?
Establish a code with family and friends to signify violence.
, 3
Have a bag ready that has extra clothes for self and children.
Plan an escape route to use if the abuser blocks the main exit. - ANSWER--The RN
is providing education about strategies for a safety plan for a female client who is
a victim of intimate partner violence. Which strategies should be included in the
safety plan? (SOA)
Nausea and vomiting. - ANSWER--The RN is admitting a male client who take
lithium carbonate (Eskalith) twice a day. Which information should the RN report
to the HCP immediately?
Monitor vital signs. - ANSWER--A male client who is admitted with delirium
tremens is dehydrated and experiencing auditory hallucinations. He has a bruised,
swollen tongue and is confused. In developing a plan of care, which action should
the RN include to ensure the client is physiologically stable?
Assign the UAP to remain with the client at all times. - ANSWER--The RN is
working with a male client at a community mental health center when the client
reports hearing voices that tell him to get a knife from the kitchen and hurt
himself. What intervention is most important for the RN to implement?
Allow the client to rest and sleep. - ANSWER--A homeless client who reports
feeling sad and depressed tells the mental health nurse that in the past 2 days she
has only had 4 hours of sleep. Which action is most important for the RN to
implement within the first 24 hours after treatment is initiated?
I am here because the police thought I was doing something wrong. - ANSWER--
Which client statement suggests the RN that the client is using a defense
