HESI RN Health Assessment Questions & Answers 2024/2025 Verified Answers A+ Guaranteed!

ATI RN MENTAL HEALTH 2019 WITH NGN 100% v v v v v v v




PASSWITH RATIONALESLATEST UPDATES
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A nurse is caring for a group of patients. For which of the following situations should the nurse
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complete an incident report? - ANS - A client was administered one-half of the prescribed dose of
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medication
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Rationale: An incident report is a recording of any occurrence that does not meet the standard of care.
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The nurse should report medication errors using the facility's incident or occurrence form.
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A nurse is caring for a group of patients. Which of the following findings is the nurse required to
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report? - ANS - A client who has borderline personality disorder threatened to harm their roommate
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Rationale: Signs and symptoms of BPD include interpersonal relationships accompanied by threats and
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other-directed violence. While it is important for the nurse to maintain the patients confidentiality,
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when another individual might be in danger, the nurse is required by law to report it to authorities.
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A nurse is caring for a patient who has borderline personality disorder. Which of the following goals is
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the priority when planning care for this patient?
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a. The patient will take the prescribed medications as scheduled b. The patient will express feelings of
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frustration
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c. The patient will refrain from self-mutilation
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d. The patient will participate in group therapy - ANS - c. The client will refrain from self- mutilation
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Rationale: The greatest risk to the patient is injury to self and others. Therefore, the priority goal is for
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the patient to refrain from self-mutilation
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a. Taking prescribed medications as scheduled to maintain therapeutic blood levels is an
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important goal. However, this is not the priority goal
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b. Expressing feelings of frustration to acknowledge these feelings is an important goal. v v v v v v v v v v v




However, this is not the priority goal v v v v v v




d. Participating in group therapy as part of the treatment plan is an important goal. However, this is not
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the priority goal
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,A nurse is discussing the home care of a patient who has advanced Alzheimer's disease. The patient's
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caregiver is planning to go out of town for several days. Which of the following resources should the
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nurse recommended to the caregiver?
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a. Respite care v




b. Partial hospitalization c. Adult day care program v v v v v v




d. Geropsychiatric unit - ANS - a. Respite care
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Rationale: Respite care programs allow the patient to stay in a nursing facility for a set number of days,
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allowing the caregivers to go on vacation or have some time to themselves
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b. Partial hospitalization provides services for several hours during the day, but they are not
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designed to offer 24-hr care. A patient with advanced Alzheimer's disease is unable to safely remain
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at home unattended
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c. Adult day care programs can provide services throughout the day to patient's with Alzheimer's
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disease, allowing the caregiver the ability to work or have a break. The patient's return home in the
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evening. A patient who has advanced Alzheimer's disease is unable to safely remain at home
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unattended.
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d. A geropsychiatric unit provides care for patients requiring acute psychiatric services due to
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sudden mental status changes, psychosis, or other mental health services. These services are ideal for
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patients who are at risk of harming themselves or others
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A nurse is caring for an older adult patient who has dementia and has wandered into the day room
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looking for their deceased partner. Which of the following actions should the nurse take?
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a. Move the patient to a room near the nurses' station v v v v v v v v v




b. Limit visitors until the patient is oriented to the environment c. Tell the patient their partner is
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deceased
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d. Talk with the patient about activities they enjoyed with their partner - ANS - Talk with the patient
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about activities they enjoyed with their partner
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Rationale:
Talking about positive experiences can help distract the patient from their disorientation
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a. When caring for a patient with dementia, avoid placing them in unfamiliar settings when
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possible.
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b. Family members should be encouraged to interact with the patient regardless of the v v v v v v v v v v v v




patient's state of dementia
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c. Confrontation should not be used for a disoriented patient v v v v v v v v




A nurse is admitting a patient with schizophrenia to an acute care setting. When the nurse questions
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the patient regarding their admission, the client states, "I'm red, in the head, and I'm
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, going to bed!" The nurse should document the client's speech pattern as which of the following?
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a. Clang association b. Word salad v v v v




c. Neologism
d. Echolalia - ANS - a. Clang association v v v v v v




Rationale: The nurse should document that the patients speech uses clang associations which often
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rhyme or contain a string of words that can have a similar sound
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b. In word salad, words are completely meaningless and disorganized. c. Neologism consists of
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words that are made up by the patient
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d. In echolalia, the patient repeats the words of another person
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A nurse is assessing a patient who has schizophrenia. Which of the following findings should the nurse
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document as a negative symptom of this disorder?
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a. Delusions b. Neologisms c. Anhedonia
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d. Echopraxia - ANS - Anhedonia
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Rationale:
Positive symptoms of schizophrenia usually appear suddenly and are alteration in behavior,
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perception, speech, and thought. Delusions, inability to think abstractly, neologisms (made up words),
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echolalia (repeating of someone else's words, motor agitation, and echopraxia (mimicking someone
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else's movements) are all positive symptoms of schizophrenia.
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Negative symptoms of schizophrenia affect a person's ability to interact with others and are less
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dominant than positive symptoms. Negative symptoms develop over time.
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Examples of negative symptoms include flat affect, anergia (lack of energy), anhedonia (inability to
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enjoy otherwise pleasurable activities), and thought blocking (inability to think, speak, or move in
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response to outside stimuli)
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A nurse is delegating patient care tasks to a licensed practical nurse (LPN) and an assistive personnel.
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Which of the following tasks should the nurse assign to the LPN? - ANS - Change the dressing of a
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client who has borderline personality disorder and superficial self-inflicted wounds
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Rationale: A patient who has borderline personality disorder is at risk for self-mutilation such as
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cutting, self-inflicted wounds, scratching or picking at wounds. It is within the LPNs scope of
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practice to change the dressing, cleanse the wound, and collect data regarding the healing of the
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wound.
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A nurse is assessing a school-age child who has conduct disorder. Which of the following
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characteristics should the nurse expect the child to demonstrate?
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