PSYCHIATRIC-MENTAL HEALTH HESI EXAM
VERIFIED ANSWERS
1.
A male client with schizophrenia who is taking fluphenazine decanoate (Prolixin
decanoate) is being discharged in the morning. A repeat dose of medication is
scheduled for 20 days after discharge. The client tells the nurse that he is going on
vacation in the Bahamas and will return in 18 days. Which statement by the client
indicates a need for health teaching?
A) When I return from my tropical island vacation, I will go to the clinic to get my
Prolixin injection.
B) While I am on vacation and when I return, I will not eat or drink anything that
contains alcohol.
C) I will notify the healthcare provider if I have a sore throat or flu-like symptoms.
D) I will continue to take my benztropine mesylate (Cogentin) every day. -
ANSWER-Photosensitivity is a side effect of Prolixin and a vacation in the
Bahamas (with its tropical island climate) increases the client's chance of
experiencing this side effect. He should be instructed to avoid direct sun (A) and
wear sunscreen. (B, C, and D) indicate accurate knowledge. Alcohol acts
synergistically with Prolixin (B). (C) lists signs of agranulocytosis, which is also a
side effect of Prolixin. In order to avoid extrapyramidal symptoms (EPS),
anticholinergic drugs, such as Cogentin, are often prescribed prophylactically with
Prolixin.
Correct Answer(s): A
,2.
A male client is admitted to the mental health unit because he was feeling
depressed about the loss of his wife and job. The client has a history of alcohol
dependency and admits that he was drinking alcohol 12 hours ago. Vital signs are:
temperature, 100° F, pulse 100, and BP 142/100. The nurse plans to give the client
lorazepam (Ativan) based on which priority nursing diagnosis?
A) Risk for injury related to suicidal ideation.
B) Risk for injury related to alcohol detoxification.
C) Knowledge deficit related to ineffective coping.
D) Health seeking behaviors related to personal crisis. - ANSWER-The most
important nursing diagnosis is related to alcohol detoxification (B) because the
client has elevated vital signs, a sign of alcohol detoxification. Maintaining client
safety related to (A) should be addressed after giving the client Ativan for elevated
vital signs secondary to alcohol withdrawal. (C and D) can be addressed when
immediate needs for safety are met.
Correct Answer(s): B
3.
The charge nurse is collaborating with the nursing staff about the plan of care for a
client who is very depressed. What is the most important intervention to implement
during the first 48 hours after the client's admission to the unit?
A) Monitor appetite and observe intake at meals.
B) Maintain safety in the client's milieu.
C) Provide ongoing, supportive contact.
D) Encourage participation in activities. - ANSWER-The most important reason
for closely observing a depressed client immediately after admission is to maintain
,safety (B), since suicide is a risk with depression. (A, C, and D) are all important
interventions, but safety is the priority.
Correct Answer(s): B
4.
A 38-year-old female client is admitted with a diagnosis of paranoid schizophrenia.
When her tray is brought to her, she refuses to eat and tells the nurse, "I know you
are trying to poison me with that food." Which response is most appropriate for the
nurse to make?
A) I'll leave your tray here. I am available if you need anything else.
B) You're not being poisoned. Why do you think someone is trying to poison you?
C) No one on this unit has ever died from poisoning. You're safe here.
D) I will talk to your healthcare provider about the possibility of changing your
diet. - ANSWER-(A) is the best choice cited. The nurse does not argue with the
client nor demand that she eat, but offers support by agreeing to "be there if
needed", e.g., to warm the food. (B and C) are arguing with the client's delusions,
and (B) asks "why" which is usually not a good question for a psychotic client. (D)
has nothing to do with the actual problem; i.e., the problem is not the diet (she
thinks any food given to her is poisoned.)
Correct Answer(s): A
5.
A client who is being treated with lithium carbonate for bipolar disorder develops
diarrhea, vomiting, and drowsiness. What action should the nurse take?
A) Notify the healthcare provider immediately and prepare for administration of an
antidote.
, B) Notify the healthcare provider of the symptoms prior to the next administration
of the drug.
C) Record the symptoms as normal side effects and continue administration of the
prescribed dosage.
D) Hold the medication and refuse to administer additional amounts of the drug. -
ANSWER-Early side effects of lithium carbonate (occurring with serum lithium
levels below 2.0 mEq per liter) generally follow a progressive pattern beginning
with diarrhea, vomiting, drowsiness, and muscular weakness. At higher levels,
ataxia, tinnitus, blurred vision, and large dilute urine output may occur. (B) is the
best choice. Although these are expected symptoms, the healthcare provider should
be notified prior to the next administration of the drug. (A, C, and D) would not
reflect good nursing judgment.
Correct Answer(s): B
6.
The parents of a 14-year-old boy bring their son to the hospital. He is lethargic, but
responsive. The mother states, "I think he took some of my pain pills." During
initial assessment of the teenager, what information is most important for the nurse
to obtain from the parents?
A) If he has seemed depressed recently.
B) If a drug overdose has ever occurred before.
C) If he might have taken any other drugs.
D) If he has a desire to quit taking drugs. - ANSWER-Knowledge of all substances
taken (C) will guide further treatment, such as administration of antagonists, so
obtaining this information has the highest priority. (A and B) are also valuable in
planning treatment. (D) is not appropriate during the acute management of a drug
overdose.
VERIFIED ANSWERS
1.
A male client with schizophrenia who is taking fluphenazine decanoate (Prolixin
decanoate) is being discharged in the morning. A repeat dose of medication is
scheduled for 20 days after discharge. The client tells the nurse that he is going on
vacation in the Bahamas and will return in 18 days. Which statement by the client
indicates a need for health teaching?
A) When I return from my tropical island vacation, I will go to the clinic to get my
Prolixin injection.
B) While I am on vacation and when I return, I will not eat or drink anything that
contains alcohol.
C) I will notify the healthcare provider if I have a sore throat or flu-like symptoms.
D) I will continue to take my benztropine mesylate (Cogentin) every day. -
ANSWER-Photosensitivity is a side effect of Prolixin and a vacation in the
Bahamas (with its tropical island climate) increases the client's chance of
experiencing this side effect. He should be instructed to avoid direct sun (A) and
wear sunscreen. (B, C, and D) indicate accurate knowledge. Alcohol acts
synergistically with Prolixin (B). (C) lists signs of agranulocytosis, which is also a
side effect of Prolixin. In order to avoid extrapyramidal symptoms (EPS),
anticholinergic drugs, such as Cogentin, are often prescribed prophylactically with
Prolixin.
Correct Answer(s): A
,2.
A male client is admitted to the mental health unit because he was feeling
depressed about the loss of his wife and job. The client has a history of alcohol
dependency and admits that he was drinking alcohol 12 hours ago. Vital signs are:
temperature, 100° F, pulse 100, and BP 142/100. The nurse plans to give the client
lorazepam (Ativan) based on which priority nursing diagnosis?
A) Risk for injury related to suicidal ideation.
B) Risk for injury related to alcohol detoxification.
C) Knowledge deficit related to ineffective coping.
D) Health seeking behaviors related to personal crisis. - ANSWER-The most
important nursing diagnosis is related to alcohol detoxification (B) because the
client has elevated vital signs, a sign of alcohol detoxification. Maintaining client
safety related to (A) should be addressed after giving the client Ativan for elevated
vital signs secondary to alcohol withdrawal. (C and D) can be addressed when
immediate needs for safety are met.
Correct Answer(s): B
3.
The charge nurse is collaborating with the nursing staff about the plan of care for a
client who is very depressed. What is the most important intervention to implement
during the first 48 hours after the client's admission to the unit?
A) Monitor appetite and observe intake at meals.
B) Maintain safety in the client's milieu.
C) Provide ongoing, supportive contact.
D) Encourage participation in activities. - ANSWER-The most important reason
for closely observing a depressed client immediately after admission is to maintain
,safety (B), since suicide is a risk with depression. (A, C, and D) are all important
interventions, but safety is the priority.
Correct Answer(s): B
4.
A 38-year-old female client is admitted with a diagnosis of paranoid schizophrenia.
When her tray is brought to her, she refuses to eat and tells the nurse, "I know you
are trying to poison me with that food." Which response is most appropriate for the
nurse to make?
A) I'll leave your tray here. I am available if you need anything else.
B) You're not being poisoned. Why do you think someone is trying to poison you?
C) No one on this unit has ever died from poisoning. You're safe here.
D) I will talk to your healthcare provider about the possibility of changing your
diet. - ANSWER-(A) is the best choice cited. The nurse does not argue with the
client nor demand that she eat, but offers support by agreeing to "be there if
needed", e.g., to warm the food. (B and C) are arguing with the client's delusions,
and (B) asks "why" which is usually not a good question for a psychotic client. (D)
has nothing to do with the actual problem; i.e., the problem is not the diet (she
thinks any food given to her is poisoned.)
Correct Answer(s): A
5.
A client who is being treated with lithium carbonate for bipolar disorder develops
diarrhea, vomiting, and drowsiness. What action should the nurse take?
A) Notify the healthcare provider immediately and prepare for administration of an
antidote.
, B) Notify the healthcare provider of the symptoms prior to the next administration
of the drug.
C) Record the symptoms as normal side effects and continue administration of the
prescribed dosage.
D) Hold the medication and refuse to administer additional amounts of the drug. -
ANSWER-Early side effects of lithium carbonate (occurring with serum lithium
levels below 2.0 mEq per liter) generally follow a progressive pattern beginning
with diarrhea, vomiting, drowsiness, and muscular weakness. At higher levels,
ataxia, tinnitus, blurred vision, and large dilute urine output may occur. (B) is the
best choice. Although these are expected symptoms, the healthcare provider should
be notified prior to the next administration of the drug. (A, C, and D) would not
reflect good nursing judgment.
Correct Answer(s): B
6.
The parents of a 14-year-old boy bring their son to the hospital. He is lethargic, but
responsive. The mother states, "I think he took some of my pain pills." During
initial assessment of the teenager, what information is most important for the nurse
to obtain from the parents?
A) If he has seemed depressed recently.
B) If a drug overdose has ever occurred before.
C) If he might have taken any other drugs.
D) If he has a desire to quit taking drugs. - ANSWER-Knowledge of all substances
taken (C) will guide further treatment, such as administration of antagonists, so
obtaining this information has the highest priority. (A and B) are also valuable in
planning treatment. (D) is not appropriate during the acute management of a drug
overdose.
