Psych/Mental Health Nursing HESI Review ALL REVISION QUESTIONS
AND CORRECT ANSWERS (GRADED 100%) (2024 UPDATE)
In conducting the initial assessment of a preoperative client, the nurse notes that the client's home
medications include the monoamine oxidase (MAO) inhibitor phenelzine. Because of this client's
medication history, which assessment finding is most important for the nurse to monitor?
A. Blood pressure
B. Urinary output
C. Temperature
D. Respiratory rate - ANSWER A. Blood pressure
The nurse has received a new prescription for the client to begin taking sertraline. Prior to
administering the initial dose of sertraline, it is most important for the nurse to obtain which
information?
A. Current weight
B. Any history of heart disease
C. Familial history of mental illness
D. Medication history - ANSWER D. Medication history
Case study: Client's speech is loud, rapid, and incoherent. She says, "Police don't see my stardom.
The stars twinkle at night. I like to eat ice cream and watch movies. Have you seen the show about
the detective and the angel? I have angels watching over me."
,Drag from Word Choices to complete the sentence:
The nurse recognizes the client's speech as ___________, __________, and ___________.
Word choices:
echolalia
loose associations
clang association
pressured
tangential
circumstantial - ANSWER loose associations, pressured, tangential
Abnormal speech patterns may be associated with psychological conditions. Pressured speech is
often loud, rapid, and incoherent. Clients may display tangentiality in their speech by adding
unnecessary details and being unable to reach a point. Conversation may drift off topic and fail to
return to the original concept. Similarly, loose associations display when thoughts are represented
in words that have limited connections to the previous statement.
Case study (cont'd): The nurse evaluates the client's presentation and considers the assessment
findings.
For each assessment finding, click to indicate whether findings from the client's assessment are
generally associated with bipolar disorder (mania), schizophrenia, or both.
Loose association
Flat or blunt affect
,Motor agitation
Elevated mood
Labile
Delusions
Low appetite - ANSWER Loose association: BOTH
Flat or blunt affect: Schizophrenia
Motor agitation: BOTH
Elevated mood: Bipolar disorder (mania)
Labile: BOTH
Delusions: BOTH
Low appetite: Bipolar disorder (mania)
Schizophrenia is traditionally characterized by a flattened or blunt affect. Meanwhile, clients with
bipolar disorder (mania) tend to have an elevated mood. Clients experiencing mania also display
low appetite and altered eating patterns. Both clients with bipolar disorder (mania) and clients with
schizophrenia share symptoms such as being labile, having delusions, using loose associations,
and having motor agitation. With lability, clients can present with emotional instability and rapidly
changing emotions. Delusions are beliefs that are not based on reality. They are also fixed and
false. With loose associations, speech patterns shod an inability to stay on point as the client brings
up unrelated ideas. Motor agitation is purposeless of unintentional restlessness, such as pacing.
, Case study (cont'd): The nurse notifies the healthcare provider about the client's behavior and the
nurse's inability to obtain an electrocardiogram.
Complete the following sentence by choosing from the list of options:
The client is most at risk for __________ as evidenced by the client's __________.
injury
psychomotor agitation - ANSWER injury; psychomotor agitation
Case study (cont'd): The nurse is planning care for the client and reviews the most recent vital
signs, notes, and orders.
Click to indicate which interventions are indicated and contraindicated for the client at this time.
Administer 5mg haloperidol and 2mg lorazepam IV.
Allow the client to express frustrations with staff.
Reassess the electrocardiogram for signs of shortening QT interval.
Apply oxygen via nasal cannula.
Monitor the client for tremors and rigidity. - ANSWER Indicated:
Allow the client to express frustrations with staff.
Monitor the client for tremors and rigidity.
Contraindicated:
Reassess the electrocardiogram for signs of shortening QT interval.
Apply oxygen via nasal cannula.
AND CORRECT ANSWERS (GRADED 100%) (2024 UPDATE)
In conducting the initial assessment of a preoperative client, the nurse notes that the client's home
medications include the monoamine oxidase (MAO) inhibitor phenelzine. Because of this client's
medication history, which assessment finding is most important for the nurse to monitor?
A. Blood pressure
B. Urinary output
C. Temperature
D. Respiratory rate - ANSWER A. Blood pressure
The nurse has received a new prescription for the client to begin taking sertraline. Prior to
administering the initial dose of sertraline, it is most important for the nurse to obtain which
information?
A. Current weight
B. Any history of heart disease
C. Familial history of mental illness
D. Medication history - ANSWER D. Medication history
Case study: Client's speech is loud, rapid, and incoherent. She says, "Police don't see my stardom.
The stars twinkle at night. I like to eat ice cream and watch movies. Have you seen the show about
the detective and the angel? I have angels watching over me."
,Drag from Word Choices to complete the sentence:
The nurse recognizes the client's speech as ___________, __________, and ___________.
Word choices:
echolalia
loose associations
clang association
pressured
tangential
circumstantial - ANSWER loose associations, pressured, tangential
Abnormal speech patterns may be associated with psychological conditions. Pressured speech is
often loud, rapid, and incoherent. Clients may display tangentiality in their speech by adding
unnecessary details and being unable to reach a point. Conversation may drift off topic and fail to
return to the original concept. Similarly, loose associations display when thoughts are represented
in words that have limited connections to the previous statement.
Case study (cont'd): The nurse evaluates the client's presentation and considers the assessment
findings.
For each assessment finding, click to indicate whether findings from the client's assessment are
generally associated with bipolar disorder (mania), schizophrenia, or both.
Loose association
Flat or blunt affect
,Motor agitation
Elevated mood
Labile
Delusions
Low appetite - ANSWER Loose association: BOTH
Flat or blunt affect: Schizophrenia
Motor agitation: BOTH
Elevated mood: Bipolar disorder (mania)
Labile: BOTH
Delusions: BOTH
Low appetite: Bipolar disorder (mania)
Schizophrenia is traditionally characterized by a flattened or blunt affect. Meanwhile, clients with
bipolar disorder (mania) tend to have an elevated mood. Clients experiencing mania also display
low appetite and altered eating patterns. Both clients with bipolar disorder (mania) and clients with
schizophrenia share symptoms such as being labile, having delusions, using loose associations,
and having motor agitation. With lability, clients can present with emotional instability and rapidly
changing emotions. Delusions are beliefs that are not based on reality. They are also fixed and
false. With loose associations, speech patterns shod an inability to stay on point as the client brings
up unrelated ideas. Motor agitation is purposeless of unintentional restlessness, such as pacing.
, Case study (cont'd): The nurse notifies the healthcare provider about the client's behavior and the
nurse's inability to obtain an electrocardiogram.
Complete the following sentence by choosing from the list of options:
The client is most at risk for __________ as evidenced by the client's __________.
injury
psychomotor agitation - ANSWER injury; psychomotor agitation
Case study (cont'd): The nurse is planning care for the client and reviews the most recent vital
signs, notes, and orders.
Click to indicate which interventions are indicated and contraindicated for the client at this time.
Administer 5mg haloperidol and 2mg lorazepam IV.
Allow the client to express frustrations with staff.
Reassess the electrocardiogram for signs of shortening QT interval.
Apply oxygen via nasal cannula.
Monitor the client for tremors and rigidity. - ANSWER Indicated:
Allow the client to express frustrations with staff.
Monitor the client for tremors and rigidity.
Contraindicated:
Reassess the electrocardiogram for signs of shortening QT interval.
Apply oxygen via nasal cannula.
