HESI RN 2018 MENTAL HEALTH V4 EXAM

1. The nurse finds the bathroom with feces and urine on the floor  Infection control 2. Pt with history of alcohol is admitted to the hospital stating he feels bugs crawling on his legs  Ativan 3. Pt taking his medication complains of chest pain  Obtain blood pressure 4. Student with anorexia wants to work in the cafeteria  Direct student to receptionist office 5. Pt taking antipsychotic medications. What else should the nurse stop giving  Cogentin 6. An alcoholic Patient  Lay the patient on the side 7. Patient says “I'm going to shoot myself”  Stop the client from leaving the unit 8. Note taking for nurses  doesn't let the nurse notice nonverbal communication signs from patients 9. Teaching plan for an abused woman. SELECT ALL  Have clothes ready for herself and children have  Exit plan just in case husband blocks the main exit  Code words with family member for violence 10. A patient with auditory hallucination is shouting out loud  Listen to what the patient is saying 11. Teenager is admitted to the unit for violence. He said he will not talk to his mom.  Has something to do with communication 12. Patient is yelling “I'm the boss” I do what I want,  Risk for violence to others 13. A coworker just found out her son was involved in car accident  Tell her how to get transportation to hospital 14. Patient with severe depression  Develop a structured plan of activities 15. What action by the coworker should the nurse intervene?  Coworker is trying to restrain the patient 16. Question with cognitive therapy  Has the words thoughts in the sentence. 17. Patient is admitted to the unit uses protection  Police brought me here, because they thought I did something wrong 18. The nurse is in therapy and passes out papers to patients about anger control. Patient interrupts and talks about pets  Redirect the patient to read the paper 19. Patient checks the locks on the doors and windows  Ask patient what her thoughts are when she checks the windows and doors 20. Patient who attempted suicide with pulls because his boss fired him. When/how does he demonstrate improvement?  When he interacts with others 21. Patient with echolalia is bothering others.  Take the patient to his room 22. Patient started yelling in the hallway and acting psychotic  Take the patient to the lounge in the patient area. PSYCH SPECIALTY HESI 2018 1. A client who is known to abuse drugs is admitted to the psychiatric unit. Which medication should the nurse anticipate administering to a client who is exhibiting benzodiazepine withdrawal symptoms? a. Perphenazine (Trilafon). b. Diphenylhydramine (Benadryl). c. Chlordiazepoxide (Librium). d. Isocarboxazid (Marplan). 2. A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care? a. Client will not demonstrate cross addiction. b. Co-dependent behaviors will be decreased. c. Excessive CNS stimulation will be reduced. d. Client's level of consciousness will increase. 3. A woman brings her 48-year-old husband to the outpatient psychiatric unit and describes his behavior to the admitting nurse. She states that he has been sleepwalking, cannot remember who he is, and exhibits multiple personalities. The nurse knows that these behaviors are often associated with which condition? a. Dissociative disorder. b. Obsessive-compulsive disorder. c. Panic disorder. d. Post-traumatic stress syndrome. 4. Which diet selection by a depressed client taking tranylcypromine sulfate (Parnate), an MAO inhibitor, indicates to the nurse that the client understands the dietary restrictions imposed by this medication regimen? a. Hamburger, french fries, and chocolate milkshake. b. Liver and onions, broccoli, and decaffeinated coffee. c. Pepperoni and cheese pizza, tossed salad, and soda. d. Roast beef, baked potato with butter, and iced tea. 5. A client who is being treated with lithium carbonate for manic depression begins to develop diarrhea, vomiting, and drowsiness. What action should the nurse take? a. Notify the physician immediately and force fluids. b. Prior to giving the next dose, notify the physician of the symptoms. c. Record the symptoms and continue medication as prescribed. d. Hold the medication and refuse to administer additional amounts of the drug. 6. A male client with schizophrenia is admitted to the mental health unit after abruptly stopping his prescription for ziprasidone (Geodon) one month ago. Which question is most important for the nurse to ask the client - Do you hear voices 7. Which client statement suggests to the nurse that the client is using the defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit ? - I am here because the police thought I was doing something wrong 8. A female client on a psychiatric unit is sweating profusely while she vigorously does pushups and then runs the length of the corridor several times before crashing in to the furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbances, the client shouts," I am the boss here. I do what I want." Which nursing problem best supports these observations - Risk for other related violence related to disruptive behavior 9. A female client engages in repeated checks of door and window locks. Behavior that prevents her form arriving on time and interferes with her ability to function effectively. What action should the nures take? - plan a list of activities to be carried out daily 10. The nurse is preparing medications for a client with disorder and notices that the antipsychotic medication was discontinued several days ago. Which medication should also be discontinued? - Benztropine (Cogentin)