HESI PN MENTAL HEALTH 1

HESI PN Mental Health 1.A nurse is collecting data from a client who is experiencing alcohol withdrawal. Which of the manifestation should the nurse expect? Answer: Diaphoresis 2. A nurse in a long-term care center is caring for an adult client who has Alzheimer’s disease and whose partner died several years ago. The client appears upset and asls the nurse when his partner will visit again. The nurse states,”It seems like you are feeling lonely. Let’s take a walk outside and talk.’ Which of the following communication strategies is the nurse using? Answer: Validation therapy 3. A nurse is reinforcing teaching with a client who has schizophrenia and a new prescription for chlorpromazine. Which of the following statements should the nurse include in the teaching? Answer:” The voices you have been hearing should decrease.” 4. A nurse isreinforcing teaching with a client who has generalized anxiety disorder and is to start therapy with buspirone. Which of the following statementsshould the nurse identify as an indication that the client understands the information? Answer: “I should expect some improvement of my symptoms in about 10 days 5. A nurse is caring for a client who has major depressive disorder(MDD). The client states.”I have nothing to live for anymore. I just can’t go on.” Which of the following responses should the nurse make? Answer: Are you thinking about ending your life 6. A nurse at an outpatient mental health clinic is assisting with a group therapy session. One of the participants is having difficulty staying seated and states loudly to the therapist.”I know more than you do about the people in this room!” The nurse should identify that which of the following findings is the likely explanation for the client’s behavior? Answer: Hypomania 7. A nurse is assisting with a mental status examination for a client who has schizophrenia. Which of the following statements should the nurse make to gather information about the client’s ability to think abstractly? Answer: How is an orange similar to an apple 8.A nurse is reinforcing teaching with the parent of a child who has ADHD and is exhibiting disruptive behaviors at home. Which of the following actions should the nurse instruct the parent to take? Answer: Initiate a pointsystem for the child 9. A nurse is collecting data from a client who is having difficulty coping with the death of his child. Which of the following questions by the nurse is the priority? Answer: Do you think about harming yourself 10. A nurse is reinforcing teaching about thought stopping with a client who has a phobia of riding in automobiles. Which of the following client statements indicates an understanding of the instructions? Answer: I will snap a rubber band on my wrist when I feel anxious about riding in a car 11. A nurse is assisting the charge nurse with the preparation for an in-service about negligence for a group of newly licensed nurses. Which of the following scenarios should the charge nurse use as an example to identify negligence? Answer: A nurse does not notify the provider of a change in condition for a client who has schizophrenia 12. A nurse in a provider’s office is collecting data from an older adult client whose adult child reports that she “seems confused and can’t seem to remember much.”Which of the following findings should lead the nurse to suspect delirium? Answer: The client’s level of consciousness changes during the interview 13. A nurse is caring for a client who gave birth to a stillborn fetus one week ago. She statesto the nurse,”I am so angry that my doctor didn’t take better care of me and my baby.” Which of the following responses should the nurse make? Answer: It is important to share what you are feeling, even if it is anger 14. A nurse is contributing to the plan of care for a client who has borderline personality disorder and exhibits manipulative behaviors. Which of the following interventions should the nurse include in the plan to address limit setting? Answer: Establish and explain consequences for the client’s behavior 15. A nurse is caring for an adult client who has visible injuries as a result of intimate partner violence. Which of the following actions should the nurse take? Answer: Encourage the client to develop a safety plan 16. A nurse in an urgent care clinic is collecting data from a client whose friend reports a suspicion of cocaine use. The nurse should identify that which of the following manifestations is an indicator of the client’s use of this substance? Answer: Hypertension 17. A nurse in a mental health facility is caring for a client who has dementia. The client’s agitation is increasing. Which of the following actions should the nurse take first? Answer: Offer diversionary activities 18. A nurse is caring for a client who has bipolar disorder. The client suddenly appears agitated and begins pacing at the end of the hallway with clenched fists. Which of the following actions should the nurse take first? Answer: Determine the client’s intentions 19. A nurse is reinforcing discharge teaching with a client who has a new prescription for alprazolam. Which of the following instructions is the priority for the nurse to include? Answer: Do not drive until your reaction to the medication is determined 20. A nurse is caring for a client who is 2 days postoperative following a hip arthroplasty. When a news report about military action comes on the television, the client says to the nurse, “My youngest child died 6 months ago while serving in the military.” Which of the following responses should the nurse make? Answer: -This must be very difficult time for you -Your child’s death must be a terrible loss -Tell me something you remember about your child 21. A nurse is contributing to the plan of care for a client who has bipolar disorder and is exhibiting mania, Which of the following interventions should the nurse include to improve the nutritional status of the client? Answer: Have the client’sfavorite snacks available at all times. 22. A nurse is collecting data from a client who has paranoid personality disorder. Which of the following manifestations should the nurse expect? Answer: Projects blame onto others 23. A nurse on and inpatient unit is assisting with a group therapy session. During the session, a client begins to shout using aggressive language. Which of the following statements should the nurse make to the client? Answer: When you raise your voice, it makes me feel uncomfortable and unsafe.” 24. A nurse is caring for a client who has schizophrenia. Which of the following actions by the nurse is a violation of the client’s confidentiality? Answer: The nurse places the client’s diagnosis on the white board in the client’s room 25. A nurse in a mental health facility is collecting data from a client who has schizophrenia. The nurse should identify that which of the following findings is referred to as a negative symptom of schizophrenia? Answer: Apathy 26. A nurse is collecting data from a client who has bulimia nervosa. Which of the following manifestations should the nurse expect? Answer: Dental caries 27. A nurse is collecting data from a client who has bipolar disorder and a history of mania. Which of the following findings should the nurse identify as an indication that the client is relapsing? Answer: Pressured speech 28. a nurse is developing countertransference toward a client during the working phase of the nurse-client relationship. To correct the situation, which of the following actions should the nurse take? Answer: Identify personal response to the client 29. A nurse is collecting data from a newly admitted client who has anorexia nervi=osa. Which of the following manifestations should the nurse expect? Answer : Peripheral edema 30. A nurse is reinforcing teaching with the family of a client who has histrionic personality disorder. Which of the following high-risk behaviorsshould the nurse instruct the family to observe for in the client? Answer: Seductive behavior 31. A nurse is collecting data from a newly admitted client. Which of the following questions should the nurse include to gather psychosocial information? Answer: Do you have a hobby that you enjoy 32. A nurse is assisting with the admission of a client who has schizophrenia. Which of the following actions should the nurse take first? Answer: Conduct an abnormal; involuntary movement scale test 33. A nurse is caring for a client who has bipolar disorder and is experiencing a manic episode. Which of the following interventions should the nurse take first? Answer: Remove harmful objectsfrom the client’s room 34. A nurse is organizing care for a group of clients. According to Maslow’s hierarchy of needs, which of the following interventions should the nurse plan to perform first? Answer: Offer finger foods to a client who is in the manic phase of bipolar disorder. 35. A nurse is contributing to the plan of care for a client who has obsessive-compulsive disorder and continually washes her hands. Which of the following interventions should the nurse include? Answer: Schedule times for the client to wash her hands during the day 36. A nurse is caring for a client in a day treatment program. Which of the following actions should the nurse take? Answer: Request transport for the client to an emergency department 37. A nurse is assisting with screening a group of clients for major depressive disorder (MDD). The nurse should identify that which of the following clients is at an increased risk for the development of MDD? Answer: A client who just gave birth 38. A nurse is caring for a client who takes naltrexone for the treatment of alcohol use disorder. The nurse should identify that which of the following client statements indicates the medication is effective? Answer: I drink less alcohol in a day while taking naltrexone 39. A nurse is preparing to administer haloperidol 3mg IM to a client. Available is haloperidol solution 5 mg/ml. how many ml should the nurse plan to administer? Answer: 0.6ml 40. A nurse is reinforcing teaching with a newly admitted client who has generalized anxiety disorder. Which of the following statements should the nurse make? Answer: We will demonstrate for you how to use relaxation techniques 41. nurse is collecting data from a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect? Answer: Pupillary dilation 42. A nurse is assisting with the planning of an interdisciplinary care conference for a newly admitted client who is in the acute stage of anorexia nervosa. Which of the following members of the interdisciplinary treatment team should the nurse includes? Answer: Dietitian 43. A nurse is assisting with discharge planning for a client who needs a day treatment center ad has limited community and financial support. Which of the following referrals should the nurse recommend for inclusion in the client’s discharge plan? Answer: Social worker 44. A nurse is speaking with a client who is expressing an intense disapproval of the current social worker. When the social worker approaches the nurse and client a few momentslater, the client cheerfully states, “Now,here is my favorite social worker!” The nurse should identify the client is using which of the following defense mechanisms? Answer: Reaction formation 45. A nurse on an inpatient unit is collecting data from a group of clients. Which of the following findings should the nurse report to the provider? Answer: A client who has borderline personality disorder and is pacing restlessly 46. A nurse is reinforcing teaching about expected withdrawal manifestations with a client who has enrolled in a smoking cessation course. Which of the following client statement indicates an understanding of the information? Answer: I will probably feel irritable within 24 hours of my last cigarette 47. A nurse is preparing to administer clozapine for the first time to a client who has schizophrenia. The nurse explainsthe therapeutic and adverse effects of the medication to the client prior to administration. Which of the following ethical concepts is the nurse demonstrating? Answer: Veracity 48. A nurse is attempting to establish a therapeutic relationship with a newly admitted client. Which of the following actions should the nurse plan to take during the working phase of the nurse-client relationship? Answer: Promote The development of problem-solving skills 49. A nurse is collecting data from a client who has major depressive disorder. Which of the following findings is the priority for the nurse to report to the provider? Answer: Feeling of hopelessness 50. A nurse on a mental health unit is prioritizing care for a group of clients. Which of the following actions should the nurse take first? Answer: Administer haloperidol to a client who has schizophrenia and is yelling at other clients.