HESI RN MENTAL HEALTH EXAM NEW FILE

HESI RN MENTAL HEALTH EXAM NEW FILE 1. 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. 2. 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 3. A female client on a psychiatric unit is sweating profusely while she vigorously does push-ups and then runs the length of the corridor several times before crashing into 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 4. What is the most important goal for a client diagnosed with major depression who has been receiving an antidepressant medication for two weeks? • not attempt to commit suicide 5. Alcohol-Pancreatitis health assessment of history of alcohol dependency WHAT ELSE WOULD BE A CONCERN? • pancreatitis 6. Anorexia Nervosa-syncope Syncope is a clinical feature of? • Abuse-BAL 7. Admission A female client with a history of drinking who was admitted 8 hours ago after receiving treatment for minor abrasions occurred from a fall at home. The nurse determines the client's blood alcohol level (BAL) was not analyzed on administration, What action should the nurse take? • Blood alcohol level- ask the client about alcohol quantity, frequency, and time of the last drink. 8. . In group therapy the charge nurse notices a client increasing to severe levels of anxiety. What should the nurse do? • Talk in a calm, approaching manner 9. A chronic depressed older man refuses to leave his room. His family moved away to a further location so they're not able to visit him as much. What approach should the nurse take with this man? • May I lay with you for a little? 10. Patient who is really depressed and won't talk or communicate, later is energetic and talkative. What should the nurse do? • Closely monitor the patient (could be suicidal) 11. Patient who had generalized anxiety disorder on Xanax long-term. What is the outcome? • Importance of not quickly stopping the drug 12. A mother has a 9-month-old baby with mental issues and growth issues. The mother comes in and says she's depressed because she’ll never have a normal baby. What should the nurse say? • Have you had any thoughts of harming your baby or yourself? 13. Lithium level 1.5. What do you tell the client who had a recent suicide attempt afterseeing him become very anxious after hearing his Lithium levels? • drink 2-3L of water in 24 hours 14. Woman comes into ED having been raped by her date. What should the nurse document? • document she stated "I was raped by my date" 15. Which patient would require CAGE assessment? • Alcohol patient, cut down, annoyed, guilty, eye opener 16. A 25-year-old client has been particularly restless and the nurse finds the client trying to leave the psychiatric unit. The client tells the nurse, "Please let me go! I must leave because the secret police are after me." Which response is best for the nurse to make? • "Come with me to your room, and I will sit with you." Rationale: 17. A 35-year-old client admitted to the psychiatric unit of an acute care hospital tells the nurse that someone is trying to poison her. The client's delusions are most likely related to which factor? • Low self-esteem 18. The nurse admits a client with depression to the mental health unit. The client reports difficulty concentrating, has lost 10 pounds in 2 weeks, and is sleeping 12 hours a day. Which outcome is most important for the client to meet by discharge? • Reports feeling better and less depressed 19. A client begins taking an atypical antipsychotic medication. The nurse must provide informed consent and education about common medication side effects. Which client education will be most important? • Maintain a balanced diet and adequate exercise. 20. The nurse is caring for a client who is taking the mood stabilizer divalproex sodium (Depakote). Which laboratory finding is most important to include in this client's record? • Liver function test results 21. An adult client who lives in a residential facility is mentally retarded and has a history of bipolar disorder. During the past week, the client has refused to wear clothes and frequently exposes their body to other residents. Which intervention should the nurse implement? . • Redirect the client to physically demanding activities. 22. A client on the psychiatric unit seeks out a particular nurse and imitates her mannerisms. Which defense mechanism does the nurse recognize in this client? • Identification 23. A nurse working in the emergency department of a children's hospital admits a child whose injuries could have been the result of abuse. Which statement most accurately describes the nurse's responsibility in cases of suspected child abuse? • Report any case of suspected child abuse. 24. Physical examination of a 6-year-old boy reveals several bite marks in various locations on his body. Xray examination reveals healed fractures of the ribs. The mother tells the nurse that her child is always having accidents. Which initial response by the nurse would be most appropriate? • "Tell me more about these accidents that your child has been having." 25. What instructions should the nurse include in the discharge teaching plan of a client who has recently been prescribed oxazepam (Serax)? (Select ALL that apply.) • Do not combine this medication with alcohol. • This medication is typically used for short-term treatment. • Avoid driving or operating equipment while taking this drug. 26. The nurse leading a group session of adolescent client gives the members a handout about anger management. One of the male clients is fidgety, interrupts peers when they try to talk, and talks about his pets at home. What nursing action is best for the nurse to take? • Redirect him by encouraging him to read from the handout. 27- A male adolescent was admitted to the unit two days ago for depression. When the mental health nurse tries to interview the client to establish rapport, he becomes very irritated and sarcastic. Which action is best for the nurse to take? • Offer to play a game of cards with the client. 28. A male adult is admitted because of an acetaminophen (Tylenol) overdose. After transfer to mental health unit the client is told he has liver damage. Which information is most important for the nurse to include in the client’s a discharge plan? • Do not take any over the counter medication. 29.After receiving treatment for anorexia, a student asks the school nurse for permission to work in the school cafeterias part of the school’s work study program. What action should the nurse take? • Recommend assignment to the receptionist’s office. 30. The nurse accepts a transfer to the mental health unit and understands that the client is distractible and is exhibiting a decreased ability to concentrate. The nurse has only 15 min to talk with the client. To develop a treatment plan for this client, wich assessment is most important for the nurse to obtain? • Mental status examination 31.A client who is known to abuse drugs is admitted to the psychiatric unit. With medication should the nurse anticipate administering to a client who is exhibiting benzodiazepine withdrawal symptoms? • Clordiazepoxide (Librium) 32.A male client who recently lost a loved one arrives at the mental health center and tells the nurse he is no longer interested in his usual activities and has not slept for several days. Which priority nursing problem should the nurse couinclude in this client’s plan of care? • Sleep deprivation 33.A woman brings her 48- years –old husband to the outpatient psychiatric unit and describes his behavior to the admitting nurse. She state that he has been sleepwalking, cannot remember who he is, and exhibits multiple personalities. The nurse knows that these behaviors are often associated with: • Dissociative disorder. 34.A male client with a long history of alcohol dependency arrives in the emergency department describing the feeling of bugs crawling on his body. His BP is 170/102. Pulse rate is 110b/min, and his blood alcohol level (BAL)is 0 mg/dl. Which prescription should • Lorazepan (Ativan) 35.The nurse on the day shift receives report about a client with depression who w the weekend. The nurse walks into the client’s room in the morning and finds the what intervention is best for the nurse to implement? • Assist the client to get out bed and involved in an activity. 36.A client who refuse antipsychotic medications disrupts group activities, talks with nonsensical words wanders into client’s room. The nurse decides that the client needs constant observation based on which of these assessment findings? • Wanders into client’s rooms. 37. A client who recently experienced the death of a significant other arrives at the mental health center. The client reports loss of interest in usual activities, expresses a wish to be with the decreased significant other, has been eating very little, and has not slept in several days. Which client statement is most important for the RN to explore at this time? • Not sleeping for several days. 38. When developing a plan of care for a client admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing problem has the highest priority? • Ineffective breathing pattern 39. When developing a plan of care for a client admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing problem has the highest priority? • Risk for other related violence related to disruptive behavior 40. A RN is preparing the physical environment to interview a new client for admission to the mental health unit. Which environmental setting facilitates the best outcome of the interview? • Reduce the noise level in the room by turning off the television and radio. 41. The mother of an 8 month old infant with profound mental and physical disabilities tells the nurse how depressed she is because she is because she realizes that her chilf will never achieve normal growth and development milestones. How should the nurse respond to this mother? • Ask the mother if she has ever thought about harming herself or child. 42. A client with schizophrenia is admitted to the psychiatric care unit for aggressive behavior, auditory hallucinations, and potential for safe harm. The client has not been taking medications as prescribed and insists that the food has been poisoned and refuses to eat. What intervention should the RN implement? • Provide the client with food in unopen containers. 43. A nurse is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? • Establish a code with family and friends to signify violence. • Plan an escape route to use if the abuser blocks the main exit. • Have a big ready that has extra clothes for self and children 44. The RN is admitting a male client who take lithium carbonate (Eskalith) twice a day. Which information should the RN report to the HCP immediately? • Nausea and vomiting 45. A male client who is admitted with delirium tremens is dehydrated and experiencing auditory hallucinations. He has a bruised, swollen tongue and is confused. In developing a plan of care, which action should the RN include to ensure the client is physiologically stable? • Monitor Vital Signs. 46. An instructor is correcting a nursing student's clinical worksheet. Which instructor statement is the best example of effective feedback? • "Surely you didn't do this deliberately, but you breached confidentiality by using the client's name." 47. After assertiveness training, a formerly passive client appropriately confronts a peer in group therapy. The group leader states, "I'm so proud of you for being assertive. You are so good!" Which communication technique has the leader employed? • The nontherapeutic technique of giving approval 48. Select the nursing interventions for a hospitalized client with mania who is exhibiting manipulative behavior. Select all that apply. • Communicate expected behaviors to the client • Assist the client in identifying ways of setting limits on personal behaviors • Follow through about the consequences of behavior in a non punitive manner • Be clear with the client regarding the consequences of exceeding limits that have been set regarding behavior 49.A nurse determines that the wife of an alcoholic client is benefitting from attending an Al-Anon group when the nurse hears the wife say: • "I no longer feel that I deserve the beatings my husband inflicts on me." 50. A nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse determines that this type of crisis is caused by: • The death of a loved one 51. A nurse is conducting an initial assessment on a client in crisis. When assessing the client's perception of the precipitating event that lead to the crisis, the appropriate question to ask is: • "What leads you to seek help now?" 52. A moderatley depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to a nurse "I'm finally cured." The nurse interprets this behavior as a cue to modify the treatment plan by: • Increasing the level of suicide precautions 53. An emergency department nurse is caring for an adult client who is a victim of family violence. Which priority instruction would be included in the discharge instructions? • Information regarding shelters 54. Bipolar patient tells the nurse that he needs to make some business deals. What should the nurse include in his plan of care? • Delay business decisions until the mania subsides 55. Bipolar patient who superficially cuts himself. How should you communicate? • Be non-judgmental Client visits clinic and asks nurse for more lithium and Elavil to help sleep. A serum creatinine was obtained. What is the reason for the lab test? • Lithium is excreted by the kidneys and creatinine is related to kidney function