HESI Comprehensive Review for
NCLEX-RN Exam Psychiatric
A 22-yr-vintage customer is admitted to the psychiatric unit from the clinical unit following a
suicide try with an overdose of diazepam. When growing the nursing care plan for this
purchaser, which action might be maximum essential for the nurse to include?
A. Assist patron to focus on personal strengths.
B. Set limits on self-defacing feedback.
C. Remind the client of each day activities inside the milieu.
D. Assist the customer to perceive why he or she turned into self-negative. - ANS-A. Assist
customer to focus on personal strengths.
Encouraging the client to recognition on his or her strengths facilitates the purchaser emerge as
aware about nice characteristics, assists in improving self-photograph, and aids in coping with
beyond and present conditions. Although nursing moves have to assist the patron in reducing
self-defacing remarks and informing the client of every day sports in the milieu, these
interventions are not priorities right now. Option D isn't as critical as supporting the purchaser to
conquer the melancholy, which resulted inside the overdose, and asking "why" isn't always
healing.
A 24-12 months-antique girl gives to the emergency department together with her first-rate
friend. She states to the consumption nurse, "My husband forces me to have intercourse with
him 2 to a few instances every day. Sometimes I tell him I don't want to, but then he receives
imply with me, forces me on my belly and has anal sex with me." What are the nurse's
subsequent movements? (Select all that observe.)
A. Tell the customer, "Having intercourse is a marital duty whether or not you want to or no
longer."
B. Ask the customer, "Why don't you need to have intercourse that frequently?"
C. Contact a S.A.N.E. Nurse.
D. Assist the customer right into a non-public examination room.
E. Insist the best friend not accompany the consumer. - ANS-C. Contact a S.A.N.E. Nurse.
D. Assist the consumer right into a non-public examination room.
Marital sexual abuse happens when the partner does now not consent to a sexual act. Asking
about the client's intentions towards nonconsensual sex is nontherapeutic and does not aid the
purchaser's chief complaint. SANE nurses are skilled in engaging in an exam for sexual abuse
sufferers. The customer needs a quiet, non-public space. The first-class buddy is the client's
guide gadget and may first of all accompany the client to help ease the transition to the clinical
surroundings.
,A 25-yr-antique purchaser has been specifically stressed, and the nurse reveals the customer
trying to depart the psychiatric unit. The consumer tells the nurse, "Please permit me go! I have
to go away because the name of the game police are after me." What is the nurse's quality
response?
A. "No one is when you. You're secure here."
B. "You'll sense better after you've got rested."
C. "I recognise you ought to experience lonely and apprehensive."
D. "Come with me to your room, and I will sit down with you." - ANS-D. "Come with me in your
room, and I will sit with you."
Option D is the quality reaction because it offers support with out judgment or demands. Option
A is challenging the client's myth. Option B is imparting false reassurance. Option C is a
violation of therapeutic communique because the nurse is telling the customer how she or he
feels (anxious and lonely), rather than permitting the consumer to describe his or her own
feelings. Hallucinating and delusional customers aren't capable of discussing their emotions,
especially after they understand a crisis.
A 25-yr-antique client has suffered vast burns and is crying in the course of dressing change
remedy. The consumer tells the nurse, "Please allow me die. Why are you all torturing me like
this? I simply want to die." Which reaction by using the nurse is first-class?
A. "We aren't torturing you. These treatments are important to save you a terrible
contamination."
B. "I understand these remedies ought to seem like torture to you, but we need that will help
you recover."
C. "You have so much to live for, and all of your circle of relatives individuals want you to live."
D. "Would you like me to name the chaplain so you can speak your emotions privately?" -
ANS-B. "I know those remedies have to appear to be torture to you, however we need that will
help you recover."
Options B gives an empathetic response without sounding patronizing. Options A is not
empathetic and is without a doubt truly argumentative. The patron is not soliciting for statistics
as an awful lot as pleading for expertise. Option C seems as scolding and places blame on the
client for trying to die and probable hurting the customer's circle of relatives participants as a
result. Option D might be appropriate if the nurse really asks the purchaser if a chaplain's go to
is desired, but the nurse is dismissing the customer's wishes by now not addressing them in the
intervening time.
A 27-year-antique client is admitted to the psychiatric health facility with a diagnosis of bipolar
disease, manic phase. The patron is worrying and active. Which action should the nurse
encompass in this customer's plan of care?
A. Schedule the customer to wait various group sports.
B. Reinforce the customer's potential to make choices.
C. Encourage the client to identify feelings of anger.
, D. Provide a dependent environment with little stimuli. - ANS-D. Provide a structured
surroundings with little stimuli.
Clients within the manic phase of a bipolar disorder require decreased stimuli and a dependent
surroundings. Noncompetitive sports that may be achieved alone should be deliberate for those
clients. Option A is contraindicated due to the fact stimuli ought to be decreased as a great deal
as viable. Impulsive selection-making is feature of clients with bipolar disease. To save you
future headaches, the nurse need to monitor those clients' selections and help them in the
decision-making process. Option C is more regularly associated with melancholy than with
bipolar disease.
A 33-12 months-old customer is admitted to a psychiatric facility with a scientific analysis of
major depression. When the nurse is assigning the consumer to a room, which roommate is
first-class for this client?
A. A 35-yr-antique client who recently tried suicide
B. A manic patron who has began lithium carbonate remedy
C. A consumer who is bipolar and is pacing the floor while telling jokes to all and sundry
D. A paranoid consumer who believes that the personnel is trying to poison the meals - ANS-B.
A manic purchaser who has started out lithium carbonate remedy
Option B appears to be the most solid purchaser defined seeing that treatment turned into
started with lithium carbonate (remedy of choice for manic despair). Being round some other
depressed character might decorate this patron's own melancholy and possibly aid suicidal
ideation. Clients in the manic stage of bipolar ailment decorate the extent of hysteria of these
around them, which could now not be healing for the patron at the moment. Paranoid ideation,
that's characterized by using suspiciousness, would additionally growth tension in this patron.
A 34-12 months-old purchaser offers to the sanatorium with a 4 month old for routine
properly-child care. The purchaser is a protracted-term patient within the clinic, and the kid has
now not been visible there earlier than. Upon evaluate of the consumer's chart, no being
pregnant was ever showed or handled within the beyond. What are the nurse's first-class
moves? (Select all that follow.)
A. Ask a coworker to alert the authorities for a capability baby abduction.
B. Stay with the consumer and reassure her that, "Everything may be all right."
C. Perform habitual take care of the little one.
D. Ask, "Is that the toddler who was abducted from the new child nursery ultimate week?"
E. Remain within the exam room and play with the newborn. - ANS-A. Ask a coworker to alert
the authorities for a capability infant abduction.
C. Perform recurring care for the toddler.
E. Remain within the examination room and play with the new child.
In this ability abduction state of affairs, the nurse need to not offer fake reassurance that the
whole thing could be all proper. Confronting the purchaser will ruin the agree with between the
nurse and the purchaser. That is an assessment for the authorities who've the vital schooling for
, this example. The little one still needs recurring care. The nurse ought to live with the client to
guarantee the infants protection.
A 35-yr-vintage customer admitted to the psychiatric unit of an acute care hospital tells the
nurse of poisoning tries. The purchaser's delusions are maximum probable associated with
which factor?
A. Authority issues in adolescence
B. Anger about being hospitalized
C. Low shallowness
D. Phobia of meals - ANS-C. Low vanity
Delusional clients have problem with agree with and have low shallowness. Nursing care have
to be directed at constructing agree with and selling fine shallowness. Activities with constrained
awareness and no competition have to be advocated to construct vanity. Options A, B, and D
aren't particularly associated with the improvement of delusions.
A 38-yr-vintage customer is admitted with a prognosis of paranoid schizophrenia. When the
lunch tray is brought to the room, the patron refuses to consume and tells the nurse, "I
recognise you are trying to poison me with that food." Which reaction by the nurse is the most
therapeutic?
A. "I'll depart your tray here. I am available if you want something else."
B. "You're now not being poisoned. Why do you believe you studied someone is trying to
poison you?"
C. "No one in this unit has ever died from poisoning. You're safe right here."
D. "I will communicate for your fitness care provider approximately the possibility of converting
your weight loss program." - ANS-A. "I'll go away your tray right here. I am to be had if you want
anything else."
Option A is the exceptional choice because the nurse does no longer argue with the patron or
demand that the client devour but offers support with the aid of agreeing to be there if wished,
which affords an open, in preference to closed, reaction to the purchaser's declaration. Options
B and C are tough the purchaser's delusions, and option B asks "why." Probing questions, which
begin with "why," are usually now not therapeutic communique for a psychotic customer. Option
D has not addressed the actual hassle—that is, the client's delusions.
A 45-year-old male client tells the nurse that he used to accept as true with that he become
Jesus Christ, however now he is aware of that he isn't always. What is the nurse's first-class
response?
A. "Did you truely trust you were Jesus Christ?"
B. "I assume you are getting well."
C. "Others have had comparable thoughts whilst underneath stress."
D. "Why did you watched you had been Jesus Christ?" - ANS-C. "Others have had similar
thoughts whilst beneath pressure."
NCLEX-RN Exam Psychiatric
A 22-yr-vintage customer is admitted to the psychiatric unit from the clinical unit following a
suicide try with an overdose of diazepam. When growing the nursing care plan for this
purchaser, which action might be maximum essential for the nurse to include?
A. Assist patron to focus on personal strengths.
B. Set limits on self-defacing feedback.
C. Remind the client of each day activities inside the milieu.
D. Assist the customer to perceive why he or she turned into self-negative. - ANS-A. Assist
customer to focus on personal strengths.
Encouraging the client to recognition on his or her strengths facilitates the purchaser emerge as
aware about nice characteristics, assists in improving self-photograph, and aids in coping with
beyond and present conditions. Although nursing moves have to assist the patron in reducing
self-defacing remarks and informing the client of every day sports in the milieu, these
interventions are not priorities right now. Option D isn't as critical as supporting the purchaser to
conquer the melancholy, which resulted inside the overdose, and asking "why" isn't always
healing.
A 24-12 months-antique girl gives to the emergency department together with her first-rate
friend. She states to the consumption nurse, "My husband forces me to have intercourse with
him 2 to a few instances every day. Sometimes I tell him I don't want to, but then he receives
imply with me, forces me on my belly and has anal sex with me." What are the nurse's
subsequent movements? (Select all that observe.)
A. Tell the customer, "Having intercourse is a marital duty whether or not you want to or no
longer."
B. Ask the customer, "Why don't you need to have intercourse that frequently?"
C. Contact a S.A.N.E. Nurse.
D. Assist the customer right into a non-public examination room.
E. Insist the best friend not accompany the consumer. - ANS-C. Contact a S.A.N.E. Nurse.
D. Assist the consumer right into a non-public examination room.
Marital sexual abuse happens when the partner does now not consent to a sexual act. Asking
about the client's intentions towards nonconsensual sex is nontherapeutic and does not aid the
purchaser's chief complaint. SANE nurses are skilled in engaging in an exam for sexual abuse
sufferers. The customer needs a quiet, non-public space. The first-class buddy is the client's
guide gadget and may first of all accompany the client to help ease the transition to the clinical
surroundings.
,A 25-yr-antique purchaser has been specifically stressed, and the nurse reveals the customer
trying to depart the psychiatric unit. The consumer tells the nurse, "Please permit me go! I have
to go away because the name of the game police are after me." What is the nurse's quality
response?
A. "No one is when you. You're secure here."
B. "You'll sense better after you've got rested."
C. "I recognise you ought to experience lonely and apprehensive."
D. "Come with me to your room, and I will sit down with you." - ANS-D. "Come with me in your
room, and I will sit with you."
Option D is the quality reaction because it offers support with out judgment or demands. Option
A is challenging the client's myth. Option B is imparting false reassurance. Option C is a
violation of therapeutic communique because the nurse is telling the customer how she or he
feels (anxious and lonely), rather than permitting the consumer to describe his or her own
feelings. Hallucinating and delusional customers aren't capable of discussing their emotions,
especially after they understand a crisis.
A 25-yr-antique client has suffered vast burns and is crying in the course of dressing change
remedy. The consumer tells the nurse, "Please allow me die. Why are you all torturing me like
this? I simply want to die." Which reaction by using the nurse is first-class?
A. "We aren't torturing you. These treatments are important to save you a terrible
contamination."
B. "I understand these remedies ought to seem like torture to you, but we need that will help
you recover."
C. "You have so much to live for, and all of your circle of relatives individuals want you to live."
D. "Would you like me to name the chaplain so you can speak your emotions privately?" -
ANS-B. "I know those remedies have to appear to be torture to you, however we need that will
help you recover."
Options B gives an empathetic response without sounding patronizing. Options A is not
empathetic and is without a doubt truly argumentative. The patron is not soliciting for statistics
as an awful lot as pleading for expertise. Option C seems as scolding and places blame on the
client for trying to die and probable hurting the customer's circle of relatives participants as a
result. Option D might be appropriate if the nurse really asks the purchaser if a chaplain's go to
is desired, but the nurse is dismissing the customer's wishes by now not addressing them in the
intervening time.
A 27-year-antique client is admitted to the psychiatric health facility with a diagnosis of bipolar
disease, manic phase. The patron is worrying and active. Which action should the nurse
encompass in this customer's plan of care?
A. Schedule the customer to wait various group sports.
B. Reinforce the customer's potential to make choices.
C. Encourage the client to identify feelings of anger.
, D. Provide a dependent environment with little stimuli. - ANS-D. Provide a structured
surroundings with little stimuli.
Clients within the manic phase of a bipolar disorder require decreased stimuli and a dependent
surroundings. Noncompetitive sports that may be achieved alone should be deliberate for those
clients. Option A is contraindicated due to the fact stimuli ought to be decreased as a great deal
as viable. Impulsive selection-making is feature of clients with bipolar disease. To save you
future headaches, the nurse need to monitor those clients' selections and help them in the
decision-making process. Option C is more regularly associated with melancholy than with
bipolar disease.
A 33-12 months-old customer is admitted to a psychiatric facility with a scientific analysis of
major depression. When the nurse is assigning the consumer to a room, which roommate is
first-class for this client?
A. A 35-yr-antique client who recently tried suicide
B. A manic patron who has began lithium carbonate remedy
C. A consumer who is bipolar and is pacing the floor while telling jokes to all and sundry
D. A paranoid consumer who believes that the personnel is trying to poison the meals - ANS-B.
A manic purchaser who has started out lithium carbonate remedy
Option B appears to be the most solid purchaser defined seeing that treatment turned into
started with lithium carbonate (remedy of choice for manic despair). Being round some other
depressed character might decorate this patron's own melancholy and possibly aid suicidal
ideation. Clients in the manic stage of bipolar ailment decorate the extent of hysteria of these
around them, which could now not be healing for the patron at the moment. Paranoid ideation,
that's characterized by using suspiciousness, would additionally growth tension in this patron.
A 34-12 months-old purchaser offers to the sanatorium with a 4 month old for routine
properly-child care. The purchaser is a protracted-term patient within the clinic, and the kid has
now not been visible there earlier than. Upon evaluate of the consumer's chart, no being
pregnant was ever showed or handled within the beyond. What are the nurse's first-class
moves? (Select all that follow.)
A. Ask a coworker to alert the authorities for a capability baby abduction.
B. Stay with the consumer and reassure her that, "Everything may be all right."
C. Perform habitual take care of the little one.
D. Ask, "Is that the toddler who was abducted from the new child nursery ultimate week?"
E. Remain within the exam room and play with the newborn. - ANS-A. Ask a coworker to alert
the authorities for a capability infant abduction.
C. Perform recurring care for the toddler.
E. Remain within the examination room and play with the new child.
In this ability abduction state of affairs, the nurse need to not offer fake reassurance that the
whole thing could be all proper. Confronting the purchaser will ruin the agree with between the
nurse and the purchaser. That is an assessment for the authorities who've the vital schooling for
, this example. The little one still needs recurring care. The nurse ought to live with the client to
guarantee the infants protection.
A 35-yr-vintage customer admitted to the psychiatric unit of an acute care hospital tells the
nurse of poisoning tries. The purchaser's delusions are maximum probable associated with
which factor?
A. Authority issues in adolescence
B. Anger about being hospitalized
C. Low shallowness
D. Phobia of meals - ANS-C. Low vanity
Delusional clients have problem with agree with and have low shallowness. Nursing care have
to be directed at constructing agree with and selling fine shallowness. Activities with constrained
awareness and no competition have to be advocated to construct vanity. Options A, B, and D
aren't particularly associated with the improvement of delusions.
A 38-yr-vintage customer is admitted with a prognosis of paranoid schizophrenia. When the
lunch tray is brought to the room, the patron refuses to consume and tells the nurse, "I
recognise you are trying to poison me with that food." Which reaction by the nurse is the most
therapeutic?
A. "I'll depart your tray here. I am available if you want something else."
B. "You're now not being poisoned. Why do you believe you studied someone is trying to
poison you?"
C. "No one in this unit has ever died from poisoning. You're safe right here."
D. "I will communicate for your fitness care provider approximately the possibility of converting
your weight loss program." - ANS-A. "I'll go away your tray right here. I am to be had if you want
anything else."
Option A is the exceptional choice because the nurse does no longer argue with the patron or
demand that the client devour but offers support with the aid of agreeing to be there if wished,
which affords an open, in preference to closed, reaction to the purchaser's declaration. Options
B and C are tough the purchaser's delusions, and option B asks "why." Probing questions, which
begin with "why," are usually now not therapeutic communique for a psychotic customer. Option
D has not addressed the actual hassle—that is, the client's delusions.
A 45-year-old male client tells the nurse that he used to accept as true with that he become
Jesus Christ, however now he is aware of that he isn't always. What is the nurse's first-class
response?
A. "Did you truely trust you were Jesus Christ?"
B. "I assume you are getting well."
C. "Others have had comparable thoughts whilst underneath stress."
D. "Why did you watched you had been Jesus Christ?" - ANS-C. "Others have had similar
thoughts whilst beneath pressure."
