Psych/Mental Health Exit HESI - Saunders
Questions and Answers latest update 2025
A client admitted to a mental health unit for treatment of psychotic behavior spends hours at the locked exit
door shouting, "Let me out. There's nothing wrong with me. I don't belong here." What defense mechanism is
the client implementing?
1. Denial
2. Projection
3. Regression
4. Rationalization - ans1. Denial
Rationale:
Denial is refusal to admit to a painful reality, which is treated as if it does not exist. In projection, a person
unconsciously rejects emotionally unacceptable features and attributes them to other persons, objects, or
situations. Regression allows the client to return to an earlier, more comforting, although less mature, way of
behaving. Rationalization is justifying illogical or unreasonable ideas, actions, or feelings by developing
acceptable explanations that satisfy the teller and the listener.
A client being seen in the emergency department immediately after being sexually assaulted appears calm and
controlled. The nurse analyzes this behavior as indicating which defense mechanism?
1. Denial
2. Projection
3. Rationalization
4. Intellectualization - ans1. Denial
Rational:
Denial is refusal to admit to a painful reality and may be a response by a victim of sexual abuse. In this case the
client is not acknowledging the trauma of the assault either verbally or nonverbally. Projection is transferring
one's internal feelings, thoughts, and unacceptable ideas and traits to someone else. Rationalization is
,justifying the unacceptable attributes about oneself. Intellectualization is the excessive use of abstract thinking
or generalizations to decrease painful thinking.
A client comes to the emergency department after an assault and is extremely agitated, trembling, and
hyperventilating. What is the priority nursing action for this client?
1. Begin to teach relaxation techniques.
2. Encourage the client to discuss the assault.
3. Remain with the client until the anxiety decreases.
4. Place the client in a quiet room alone to decrease stimulation. - ans3. Remain with the client until the anxiety
decreases.
Rationale:
This client is in a severe state of anxiety. When a client is in a severe or panic state of anxiety, it is crucial for
the nurse to remain with the client. The client in a severe state of anxiety would be unable to learn relaxation
techniques. Discussing the assault at this point would increase the client's level of anxiety further. Placing the
client in a quiet room alone may also increase the anxiety level.
A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the
nurse implement initially?
1. Move the client next to the nurse's station.
2. Use an indirect light source and turn off the television.
3. Keep the television and a soft light on during the night.
4. Play soft music during the night, and maintain a well-lit room. - ans2. Use an indirect light source and turn off
the television.
Rationale:
Provision of a consistent daily routine and a low stimulating environment is important when a client is
disoriented. Noise, including radio and television, may add to the confusion and disorientation. Moving the
client next to the nurses' station may become necessary but is not the initial action.
,A client diagnosed with terminal cancer says to the nurse, "I'm going to die, and I wish my family would stop
hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying." Which
response by the nurse is therapeutic?
1. "Have you shared your feelings with your family?"
2. "I think we should talk more about your anger with your family."
3. "You're feeling angry that your family continues to hope for you to be cured?"
4. "You are probably very depressed, which is understandable with such a diagnosis." - ans3. "You're feeling
angry that your family continues to hope for you to be cured?"
Rationale:
Restating is a therapeutic communication technique in which the nurse repeats what the client says to show
understanding and to review what was said. While it is appropriate for the nurse to attempt to assess the
client's ability to discuss feelings openly with family members, it does not help the client discuss the feelings
causing the anger. The nurse's attempt to focus on the central issue of anger is premature. The nurse would
never make a judgment regarding the reason for the client's feeling; this is nontherapeutic in the one-to-one
relationship.
A client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which
statement by the client indicates a need for further teaching about the therapy?
1. "This form of therapy can be applied to new situations."
2. "An advantage of this technique is that change is likely to last."
3. "Talking to oneself is a basic component of this form of therapy."
4. "This form of therapy provides a negative reinforcement when the stimulus is produced." - ans4. "This form
of therapy provides a negative reinforcement when the stimulus is produced."
Rationale:
Negative reinforcement when the stimulus is produced is descriptive of aversion therapy. Options 1, 2, and 3
are characteristics of self-control therapy.
, A client experiencing disturbed thought processes believes that his food is being poisoned. Which
communication technique should the nurse use to encourage the client to eat?
1. Using open-ended questions and silence
2. Sharing personal preference regarding food choices
3. Documenting reasons why the client does not want to eat
4. Offering opinions about the necessity of adequate nutrition - ans1. Using open-ended questions and silence
Rationale:
Open-ended questions and silence are strategies used to encourage clients to discuss their problems. Sharing
personal food preferences is not a client-centered intervention. The remaining options are not helpful to the
client because they do not encourage the client to express feelings. The nurse should not offer opinions and
should encourage the client to identify the reasons for the behavior.
A client has been diagnosed with major depression. The nurse notes that the client is not eating adequately
and at times refuses to eat. What should the nurse plan to do to meet the client's nutritional needs?
1. Force foods and fluids.
2. Provide small, frequent meals.
3. Provide snacks and meals as requested.
4. Tell the client that social activities will be restricted unless food intake is increased. - ans2. Provide small,
frequent meals.
Rationale:
A depressed client may eat small amounts of food because large amounts may seem overwhelming. If the
client becomes overwhelmed, he or she may respond by withdrawing further. Providing snacks and meals
when the client requests them will not ensure adequate nutritional intake. Forcing foods and fluids and telling
the client that social activities will be restricted will cause further withdrawal by the client. Telling the client
that social activities will be restricted also is a demeaning action.
Questions and Answers latest update 2025
A client admitted to a mental health unit for treatment of psychotic behavior spends hours at the locked exit
door shouting, "Let me out. There's nothing wrong with me. I don't belong here." What defense mechanism is
the client implementing?
1. Denial
2. Projection
3. Regression
4. Rationalization - ans1. Denial
Rationale:
Denial is refusal to admit to a painful reality, which is treated as if it does not exist. In projection, a person
unconsciously rejects emotionally unacceptable features and attributes them to other persons, objects, or
situations. Regression allows the client to return to an earlier, more comforting, although less mature, way of
behaving. Rationalization is justifying illogical or unreasonable ideas, actions, or feelings by developing
acceptable explanations that satisfy the teller and the listener.
A client being seen in the emergency department immediately after being sexually assaulted appears calm and
controlled. The nurse analyzes this behavior as indicating which defense mechanism?
1. Denial
2. Projection
3. Rationalization
4. Intellectualization - ans1. Denial
Rational:
Denial is refusal to admit to a painful reality and may be a response by a victim of sexual abuse. In this case the
client is not acknowledging the trauma of the assault either verbally or nonverbally. Projection is transferring
one's internal feelings, thoughts, and unacceptable ideas and traits to someone else. Rationalization is
,justifying the unacceptable attributes about oneself. Intellectualization is the excessive use of abstract thinking
or generalizations to decrease painful thinking.
A client comes to the emergency department after an assault and is extremely agitated, trembling, and
hyperventilating. What is the priority nursing action for this client?
1. Begin to teach relaxation techniques.
2. Encourage the client to discuss the assault.
3. Remain with the client until the anxiety decreases.
4. Place the client in a quiet room alone to decrease stimulation. - ans3. Remain with the client until the anxiety
decreases.
Rationale:
This client is in a severe state of anxiety. When a client is in a severe or panic state of anxiety, it is crucial for
the nurse to remain with the client. The client in a severe state of anxiety would be unable to learn relaxation
techniques. Discussing the assault at this point would increase the client's level of anxiety further. Placing the
client in a quiet room alone may also increase the anxiety level.
A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the
nurse implement initially?
1. Move the client next to the nurse's station.
2. Use an indirect light source and turn off the television.
3. Keep the television and a soft light on during the night.
4. Play soft music during the night, and maintain a well-lit room. - ans2. Use an indirect light source and turn off
the television.
Rationale:
Provision of a consistent daily routine and a low stimulating environment is important when a client is
disoriented. Noise, including radio and television, may add to the confusion and disorientation. Moving the
client next to the nurses' station may become necessary but is not the initial action.
,A client diagnosed with terminal cancer says to the nurse, "I'm going to die, and I wish my family would stop
hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying." Which
response by the nurse is therapeutic?
1. "Have you shared your feelings with your family?"
2. "I think we should talk more about your anger with your family."
3. "You're feeling angry that your family continues to hope for you to be cured?"
4. "You are probably very depressed, which is understandable with such a diagnosis." - ans3. "You're feeling
angry that your family continues to hope for you to be cured?"
Rationale:
Restating is a therapeutic communication technique in which the nurse repeats what the client says to show
understanding and to review what was said. While it is appropriate for the nurse to attempt to assess the
client's ability to discuss feelings openly with family members, it does not help the client discuss the feelings
causing the anger. The nurse's attempt to focus on the central issue of anger is premature. The nurse would
never make a judgment regarding the reason for the client's feeling; this is nontherapeutic in the one-to-one
relationship.
A client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which
statement by the client indicates a need for further teaching about the therapy?
1. "This form of therapy can be applied to new situations."
2. "An advantage of this technique is that change is likely to last."
3. "Talking to oneself is a basic component of this form of therapy."
4. "This form of therapy provides a negative reinforcement when the stimulus is produced." - ans4. "This form
of therapy provides a negative reinforcement when the stimulus is produced."
Rationale:
Negative reinforcement when the stimulus is produced is descriptive of aversion therapy. Options 1, 2, and 3
are characteristics of self-control therapy.
, A client experiencing disturbed thought processes believes that his food is being poisoned. Which
communication technique should the nurse use to encourage the client to eat?
1. Using open-ended questions and silence
2. Sharing personal preference regarding food choices
3. Documenting reasons why the client does not want to eat
4. Offering opinions about the necessity of adequate nutrition - ans1. Using open-ended questions and silence
Rationale:
Open-ended questions and silence are strategies used to encourage clients to discuss their problems. Sharing
personal food preferences is not a client-centered intervention. The remaining options are not helpful to the
client because they do not encourage the client to express feelings. The nurse should not offer opinions and
should encourage the client to identify the reasons for the behavior.
A client has been diagnosed with major depression. The nurse notes that the client is not eating adequately
and at times refuses to eat. What should the nurse plan to do to meet the client's nutritional needs?
1. Force foods and fluids.
2. Provide small, frequent meals.
3. Provide snacks and meals as requested.
4. Tell the client that social activities will be restricted unless food intake is increased. - ans2. Provide small,
frequent meals.
Rationale:
A depressed client may eat small amounts of food because large amounts may seem overwhelming. If the
client becomes overwhelmed, he or she may respond by withdrawing further. Providing snacks and meals
when the client requests them will not ensure adequate nutritional intake. Forcing foods and fluids and telling
the client that social activities will be restricted will cause further withdrawal by the client. Telling the client
that social activities will be restricted also is a demeaning action.
