HESI RN MENTAL HEALTH

HESI RN MENTAL HEALTH EXAM 1- A client with depression remains in bed most of the day, declines activities and re which nursing problem has the greatest priority for this client? A) Loss of interest in diversional activity B) Social isolation C) Refusal to address nutritional needs. D) Low self-esteem 2- The nurse is preparing medications for a client with bipolar disorder and notice antipsychotic medication was discontinued several days ago. Which medication discontinued? A) Lithium (lithotabs) B) Benztropine (cogetin) C) Alprazolam ( Xanax) D) Magnesium (milk of magnesia) 3- A female client requests that her husband be allowed to stay in the room during the admission assessment. While interviewing the client, the nurse notes a discrepancy between the client’s verbal and nonverbal communication. What action should the nurse take? A) Pay close attention and document the nonverbal message. B) Ask the client’s husband to interpret the discrepancy C) Ignore the nonverbal behavior and focus on the client’s verbal message. D) Integrate the verbal and nonverbal message and interpret them as one. 4- A male client approaches the nurse with an angry expression on his face and raises his voice, saying, “My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch out! “the nurse recognizes that client is using which defense mechanism? A) Denial B) Projection C) Rationalization D) Splitting 5- A male client with bipolar disorder who began taking lithium carbonate five days ago is complaining of excessive thirst, and the nurse finds him attempting to drink water from the bathroom sink faucet. Which intervention the nurses implement? A) Report the client’s serum lithium level to the healthcare provider. B) Encourage the client to suck on hard candy to relieve the symptoms. C) No action is needed since polydipsia is a common side effect. D) Tell the client that drinking from the faucet is not allowed. 6- The nurse is teaching a client about the initiation of a prescribed abstinence therapy using disulfiram (antabuse). What information should the client acknowledge understanding? A) Completely abstain from heroin or cocaine use. B) Remain alcohol free for 12 hours prior to the first dose. C) Attend monthly meeting of alcoholics anonymous. D) Admit to other that he is a substance abuser. 7- 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? A) Have you lost interest in the things that you used to enjoy? B) Is your ability to think or concentrate decreased? C) How many continuous hours do you sleep at night? D) Do you hear sounds or voices that others do not hear? 8- During an annual physical by the occupational nurse working in a corporate clinic, a male employee tells the nurse that his high-stress job is causing trouble in his personal life. He further explains that he often gets so angry while driving to and from work that he has considered “getting even” with other drivers. How should the nurse respond? A) “Anger is contagious and could result in a major confrontation” B) “ Try not to let your anger cause you to act impulsively” C) “Expressing your anger to a stranger could result in an unsafe situation” D) “It sound as if there are many situations that make you feel angry” 9- A client who has agoraphobia (a fear of crowds) is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client’s plan of care? A) Encourage substitution of positive thoughts for negative ones. B) Establish trust by providing a calm, safe environment. C) Progressively expose the client to larger crowds. D) Encourage deep breathing when anxiety escalates in a crowd. 10- Which nursing actions are likely to help promote the self-esteem of a male client with moderate depression? ( select all that apply) A) Ask the client what his long- term goals are. B) Discuss the challenges of his medical condition. C) Include the client in determining treatment protocol. D) Encourage the client to engage in recreational therapy. E) Provide opportunities for the client to discuss his concerns. 11- A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone (Risperdal). When the client walks to the nurse’s station in a literally contracted position, he states that something has made his body confort into a monster. What action should the nurse take? A) Medicate the client with the prescribed antipsychotic thioridazine (mellaril) B) Offer the client a prescribed physical therapy hot pack for muscle spasms. C) Direct client to occupational therapy to distract him from somatic complaints. D) Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia. 12- A mental health worker (MHW) is caring for a client with escalating aggressive behavior. Which action by the MHW warrants immediate intervention by the nurse? A) Is attempting to physically restrain the client. B) Tells the client to go to the quiet area of the unit. C) Is using a loud voice to talk to the client. D) Remains at a distance of 4 feet from the client. 13- A client on the mental health unit is becoming more agitated, shouting at the staff, and pacing in the hallway. When a PRN medication is offered, the client refuses the medication and defiantly sits on the floor in the middle of the unit hallway. What nursing intervention should the nurse implement first? A) Transport of the client to the seclusion room B) Quietly approach the client with additional staff members. C) Take other client in the area to the client lounge. D) Administer medication to chemically restrain the client. 14- A client is admitted to the mental health unit and reports taking extra antianxiety medication because, “I’m so stressed out. I just wanted to go sleep” the nurse should plan one-on- one observation of the client based on which statement? A) What should I do? Nothing seems to help.” B) I have been so tired lately and needed to sleep.” C) I really think that I don’t need to be here.” D) I don’t want to talk. Nothing matters anymore.” 15- A male hospital employee is pushed out of the way by a female employee because of an oncoming gurney. The pushed employee becomes very angry and swings at the female employee. Both employees are referred for counseling with the staff psychiatric nurse. Which factor in the pushed employee’s history is most related to the reaction that occurred? A) Is worried about losing his job to a woman B) Tortured animals as a child. C) Was physically abused by his mother D) Hates to be touched by anyone 16- The nurse documents the mental status of a female client who has been hospitalized for several days by court order. The client state, “I don’t need to be here” and tells the nurse that she believes that the television talks to her. The nurse should document these assessment findings in which section of the mental status exam? A) Level of concentration B) Insight and judgment C) Remote memory D) Mood and affect 17- The nurse on the evening shift receives report that a client is scheduled for electroconvulsive treatment (ECT) in the morning. Which intervention should the nurse implement the evening before the scheduled ECT? A) Hold all bedtime medication. B) Keep the client NPO after midnight. C) Implement elopement precautions. D) Give client an enema at bedtime. 18- A client who is admitted to the mental health unit report shortness of breath and dizziness. The client tells the nurse, “I feel like I’m going to die” which nursing problem should the nurse include in this client’s plan of care? A) Mood disturbance B) Moderate anxiety C) Altered thoughts D) Social isolation 19- A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confuse. The nurse also determines that the client is homeless and slightly suspicious. This client’s treatment plan should include what priority problem? A) Self-care deficit. B) Disturbed sensory perception. C) Ineffective community coping. D) Acute confuse. 20- 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? (Select all that apply) A) Have a bag ready that has extra clothes for self and children. B) Establish a code with family and friend to signify violence. C) Purchase a gun to use for protection D) Take a self-defense course that retaliate the abuser with injury. E) Plan an escape route to use if the abuser blocks the main exit. 21- A female client, who is wearing dirty clothes and has a foul body odor, comes to the clinic reporting feeling scared because she is being stalked. What A) Offer the client a safe place to relax before interviewing her. B) Ask the client to describe why she is being stalked. C) Recommend that the client talk with a social worked. D) Assure client that the healthcare provider will see her today. 22- 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? A) Explore the client’s feelings about his pet and home life. B) Encourage his peers to help involve him in the activity. C) Give the client permission to leave and return in 10 min. D) Redirect him by encouraging him to read from the handout. 23- 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? A) Report the behavior to the next shift. B) Offer to play a game of cards with the client. C) Document the behavior in the chart. D) Plan to talk with the client the next day. 24- 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? A) Eat a high carbohydrate, low fat, low protein diet. B) Do not take any over the counter medication. C) Call the crisis hot line if feeling lonely. D) Avoid exposure to large crowds. 25- 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? A) Refer the student to a psychiatrist for further discussion. B) Recommend assignment to the receptionist’s office. C) Suggest that the student work in the athletic department. D) Determine the parents’ opinion of the work assignment. 26- 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? A) Motivation for treatment B) History of substance use C) Medication compliance D) Mental status examination 27- 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? A) Diphenhydramine (Benadryl) B) Perphenazine (trilafon) C) Isocarboxazid (marplan) D) Clordiazepoxide (Librium) 28- 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? A) Risk for suicide B) Sleep deprivation C) Situational low self-esteem. D) Social isolation. 29- 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: A) Post-traumatic stress syndrome. B) Panic disorder. C) Dissociative disorder. D) Obsessive-compulsive disorder. 30- 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 the nurse administer? A) Haloperidol (Haldol) B) Thiamine (Vit B1) C) Diphenhydramine (Benadryl) D) 31- 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? A) Assist the client to get out bed and involved in an activity. B) Monitor the client’s appetite and pattern of sleep. C) Assess the client’s feelings about the hospital stay. D) Explain that staff will check on the client every 30 min 32- 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? A) Wanders into client’s rooms. B) Refuse antipsychotic medication. C) Talks with nonsensical words. D) Disrupts group activities. 33- 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? A) I am here because the police thought I was doing something wrong” B) I want to be here because I know it is the best psychiatric facility” C) At least I hit the wall instead of hitting the psychiatric aide” D) Don’t believe everything my family tells you, I am not crazy” 34- A client with schizophrenia explains that she has 20 children and then very seriously points to the nurse and explains that she is one of them. What is the most therapeutic response for the nurse to provide? A) Let’s go ask another nurse if this true.” B) My name tag shows that I am a nurse here.” C) I cannot possibly be one of your children” D) I know that you don’t have 9 children” 35- A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and amotivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning? A) Encourage the client to exercise B) Suggest that the client to develop a list of pleasurable activities C) Teach the client to develop a plan for daily structured activities D) Provide education on methods to enhance sleep 36- A high school girl reveals to the school nurse that she has been engaging in self-induced vomiting as a weight-control measure. Which initial assessment should the nurse focus on with this adolescent? A) National percentile of weight and height. B) Frequency of bingeing and purging behaviors C) Perceptions of family and social relationships D) School grades and extracurricular activities. 37- A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care? A) Excessive CNS stimulation will be reduce B) Co- dependent behaviors will be decreased C) Client’s level of consciousness will increase. D) Client will not demonstrate cross- addiction 38- 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 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 the disturbance, the client shouts, “I am the boss here. I do what I want” which nursing problem best supports these observation? A) Deficient diversional activity related to excess energy level B) Disturbed personal identity related to grandiosity C) Risk for activity intolerance related to hyperactivity D) Risk for other related violence related to disruptive behaviors 39- Narcan was administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate (vicodin). Within 15 min the client is alert and oriented. In planning nursing care which intervention has the highest priority at this time? A) Encourage the client to increase fluid intake. B) Obtain the client’s serum vicodin level C) observe the client for further narcotic effects D) determine the client’s reason for attempting suicide 40- Following surgery, a male client with antisocial personality disorder frequently request that a specific nurse be assigned to his care and is belligerent when another nurse is assigned. What action should the charge nurse implement? A) Reassure the client that his request will be met whenever possible B) Advise the client that assignments are not based on client requests C) Ask the client to explain why he constantly request the nurse D) Encourage the client to verbalize his feelings about the nurse 41- A client postpartum depression receives prescription for sertraline (Zoloft). What information is most important to include in client teaching? A) Avoid processed meats, red, wine, and Swiss cheese B) Contact the healthcare provider immediately if suicidal thoughts occur. C) Increase activity level to include a daily exercise routine D) Contact the healthcare provider immediately if muscle stiffness 42- When preparing to administer a prescribed medication to a homeless male at a community psychiatric clinic the client tells the nurse that he usually takes a different dosage. What action should the nurse take? A) Tell him to take the medication then verify the dosage at the next healthcare team meeting B) Withhold the medication until the dosage can be confirmed C) Inform him that he may refuse the medication and document whether or not he take it D) Explain to the client that the dosage has been changed 43- A client who is being treated with lithium carbonate for bipolar disorder develops diarrhea, vomiting and drowsiness. What action should the nurse take? A) Notify de healthcare provider immediately and prepare for admon of an antidote B) Hold the medication and refuse to admon additional amounts of the drug C) Record the symptoms as normal side effects and continues admon of the prescribed dosage D) Notify the health care provider of the symptoms prior to the next admon of the drug 44- The nurse orients a female client with depression to her new room on the mental unit. The client state, “ It seems strange that I don’t have a tv in my room”. Which statement would be best for the nurse to provider? A) You can watch TV as much as you want ouside of your room B) Sometime client feel like the TV is sending them messages C) It’s important to be out of your room and talking to others D) Watching TV is a passive activity and we want you to be active 45- A client who is admitted with a closed head injury after a fall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 h following admission should the nurse identify as the priority? A) Give lorazepan ( Ativan) PRN for signs of withdrawal B) Administer disulfiram (antabuse) immediately C) Place in side-lying position with head of bed elevated D) Provide thiamine and folate supplements as prescribed 46- The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking helpbecause his wife said he had a drinking problem. What information should the nurse explore indepth with the client based on this screening tool? A) Cancer screening result angerv gastritis daily alcohol intake. B) Consumptiom, liver enzyme gastrointestinal complaints and bleeding C) Efforts to cut down annoyance with question guilt drinking as an eye opener D) Minimizes drinking frequently misses family event guilt about drinking amount of daily intake 47- A female client engages in repeated checks of door and a window lock behavior that prevents her from arriving on time and interferes with her ability to function effectively. What action should the nurse take? A) Ask the client why she checks the locks B) Discuss checking the time frequently C) Determine the type and size of the locks D) Plan a list of activities to be carried out daily 48- The nurse complete an assessment of a client who is experiencing intimate partner violence (IPV) which finding of the injuries should the nurse include in the documentation? A) The client’s significant other’s statement B) Photographs C) General description D) A summary of the client’s feelings 49- The nurse is completing the admission assessment of and underweight adolescent who is admitted to a psychiatric unit with a diagnosis of depression. Which finding requires notification to the healthcare provider? A) Potassium level 2,9 mEq/dl B) BP of 110/70 mm/hg C) WBC of 10,000 mm3 D) Body mass index of 21 50- The nurse is planning client teaching for a 35 year old client with early alcoholic cirrhosis. Which self-care measure should the nurse emphasize for the client’s recovery? A) Support group meetings B) Vit B and multivitamin supplement C) Diet with adequate calories and protein D) Alcohol abstinence 51- A male client comes to the emergency center he has an erection that will no resolve the client reports that he is taking trazodone (desyrel) for insomnia which information is most important for the nurse to ask this client? A) Have you taken any medication for erectile dysfunction?” B) Are you having any other sexual dysfunctions or problems?” C) When was the last time you drank an alcoholic beverage?” D) Do you have a history of angina or high BP?” 52- A teenager who has lost 20 pounds in the last three months is admitted to the hospital with hypotension and tachycardia. The client reports irregular menses and hair loss. Which intervention is most important for the nurse to include in the client plan of care? A) Implement behaviors modification therapy. B) Indicate caloric and nutritional therapy. C) Evaluate the client for low self- esteem. D) Record daily weights and graft trend. 53- While interviewing a client, the nurse takes notes to assist with accurate documentation later. Which statement is most accurate regarding note-take during an interview? A) The client’s comfort level is increased when the nurse breaks eye contact to take notes. B) The interview process is enhanced with note taking and allows the client’s to speak at a normal pace. C) Taken note during an interview is a legal obligation of the examining nurse. D) The nurse’s ability to directly observe the client’s nonverbal communication is limited with note taking. 54- A male client with bipolar disorder tells the nurse that the needs to “ make some deals so that he can improve his retirement savings “ based on this information, which client outcome should the nurse include in the plan of care? A) Delay business decisions until his mania subsides. B) Identify the feeling associated with his behaviors C) Seek legal counsel when making business decisions D) Describe why he is feeling fearful about his finances