Psych/Mental Health Exit HESI - Saunders Exam
Latest Update 100% Pass
The home care nurse is visiting an older client whose spouse died 6 months ago. Which
behavior by the client indicates ineffective coping?
1. Neglecting personal grooming
2. Looking at old snapshots of family
3. Participating in a senior citizens' program
4. Visiting their spouse's grave once a month - Answer 1. Neglecting personal grooming
Rationale:
Coping mechanisms are behaviors used to decrease stress and anxiety. In response to
a death, ineffective coping is manifested by an extreme behavior that in some cases may
be harmful to the individual physically or psychologically. The correct option is
indicative of a behavior that identifies an ineffective coping behavior in the grieving
process.
A client is admitted with major depression and a history of a suicide attempt. The client
says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right
for me." Which response by the nurse is an example of therapeutic communication?
1. "You have everything to live for."
2. "Why do you see yourself as a failure?"
3. "Feeling like this is all part of being depressed."
4. "You've been feeling like a failure for a while?" - Answer 4. "You have been made to
feel like a failure for some time?"
Rationale:
,A therapeutic way of responding to feelings expressed by the client is through
responding. The correct option is the use of reiterating. All the other options are closing
responses as it minimizes the client's experience and there is no exploration into the
feelings expressed by the client. Also, the use of the word "why" is not therapeutic.
When visiting a client at home, the client states to the mental health nurse, "I haven't
slept at all the last couple of nights." Which response by the nurse is an example of a
therapeutic communication response to this client?
1. "I see."
2. "Really?"
3. "You're having difficulty sleeping?"
4. "Sometimes, I have trouble sleeping too." - Response 3. "You're having difficulty
sleeping?"
Rationale:
The correct option applies the restatement therapeutic communication skill. Although
this is a skill that does have a cueing element to it, the core of the restatement is the
repetition of the client's main theme, which allows the nurse to start to understand the
issue for the client more clearly. The other options are not therapeutic responses
because none of them encourage the client to expand on the concern. Sharing personal
experience takes the discussion off the client and onto the nurse.
A client with disturbed thought processes believes that his food is being poisoned. What
is the most appropriate communication technique by the nurse that would encourage
the client to eat?
1. The use of open-ended questions and silence
2. Discussing personal preference in relation to food choices
3. Recording why the client does not wish to eat
4. Expressing opinions about the need for adequate nutrition - Answer 1. The use of
open-ended questions and silence
Rationale:
,Strategies to get the client talking about their problems include open-ended questions
and silence. Sharing personal food preferences is not a client-centered intervention.
The other options are not supportive of the client because they fail to lead the client into
an expression of feeling. The nurse should not give an opinion and should lead the client
to determine the rationale for the behavior.
A client is admitted to a psychiatric unit for treatment of psychotic behavior. The client
spends hours at the locked exit door shouting, "Let me out. There's nothing wrong with
me. I don't belong here." Which defense mechanism is the client utilizing?
1. Denial
2. Projection
3. Regression
4. Rationalization - Answer 1. Denial
Rationale:
Denial is the refusal to admit to a painful reality, which is treated as if it does not exist.
Projection involves the unconscious rejection of emotionally unacceptable features and
attributing it to other persons, objects, or situations. Regression allows the client to
return to an earlier, more comforting although less mature way of behaving.
Rationalization is justifying illogical or unreasonable ideas, actions, or feelings by
developing acceptable explanations that satisfy the teller and the listener.
A patient with terminal cancer says to the nurse, "I'm going to die, and I wish my family
would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the
one who's dying." Which response by the nurse is therapeutic?
1. "Have you shared your feelings with your family?"
2. "I think we should talk more about your anger with your family."
3. "You're angry feeling your family continues to hope for you to be cured?"
4. "You must be very depressed, which of course is understandable with such a
diagnosis." Response 3. "You're angry feeling your family continues to hope for you to
be cured?"
, Rationale:
Restating is a therapeutic communication technique where the nurse repeats back to
the client what he says to show that he has understood and to review what has been
said. While it is appropriate for the nurse to attempt to assess the client's ability to
discuss feelings openly with family members, it does not help the client discuss the
feelings causing the anger. The nurse's attempt to focus on the central issue of anger is
premature. The nurse would never make a judgment regarding the reason for the
client's feeling; this is nontherapeutic in the one-to-one relationship.
While conducting a review of the client's record, the nurse learns that the client was
voluntarily admitted because of their mental health problem. With this in mind, the nurse
would be able to anticipate which of the following responses the client might give?
1. Fears about the treatment interventions
2. Hostility and aggression towards others
3. Understanding about the pathology and symptoms associated with the diagnosis.
4. A wish to be involved in the planning of the care and treatment plan. -Answer 4. A
wish to be involved in the planning of the care and treatment plan.
Rationale:
Generally speaking, clients request voluntary admissions. In such cases, if a client
requests admission as a volunteer, most likely a client will cooperate with the treatment
program since they are looking for help themselves. The rest of the options are not
characteristics of this type of admission. Fearfulness, anger, and aggressiveness are
more typical for an involuntary admission. Voluntary admission cannot guarantee a
client's understanding of his or her illness, only the understanding of his or her desire
for help.
The nurse is reviewing the admission assessment and finds that this client was admitted
to the mental health unit involuntarily. This type of admission would necessitate that the
nurse implement which of the following interventions for this client?
nimi
1. Closely monitor for harm to self or others.
2. Assist client in completing an application for admission.
Latest Update 100% Pass
The home care nurse is visiting an older client whose spouse died 6 months ago. Which
behavior by the client indicates ineffective coping?
1. Neglecting personal grooming
2. Looking at old snapshots of family
3. Participating in a senior citizens' program
4. Visiting their spouse's grave once a month - Answer 1. Neglecting personal grooming
Rationale:
Coping mechanisms are behaviors used to decrease stress and anxiety. In response to
a death, ineffective coping is manifested by an extreme behavior that in some cases may
be harmful to the individual physically or psychologically. The correct option is
indicative of a behavior that identifies an ineffective coping behavior in the grieving
process.
A client is admitted with major depression and a history of a suicide attempt. The client
says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right
for me." Which response by the nurse is an example of therapeutic communication?
1. "You have everything to live for."
2. "Why do you see yourself as a failure?"
3. "Feeling like this is all part of being depressed."
4. "You've been feeling like a failure for a while?" - Answer 4. "You have been made to
feel like a failure for some time?"
Rationale:
,A therapeutic way of responding to feelings expressed by the client is through
responding. The correct option is the use of reiterating. All the other options are closing
responses as it minimizes the client's experience and there is no exploration into the
feelings expressed by the client. Also, the use of the word "why" is not therapeutic.
When visiting a client at home, the client states to the mental health nurse, "I haven't
slept at all the last couple of nights." Which response by the nurse is an example of a
therapeutic communication response to this client?
1. "I see."
2. "Really?"
3. "You're having difficulty sleeping?"
4. "Sometimes, I have trouble sleeping too." - Response 3. "You're having difficulty
sleeping?"
Rationale:
The correct option applies the restatement therapeutic communication skill. Although
this is a skill that does have a cueing element to it, the core of the restatement is the
repetition of the client's main theme, which allows the nurse to start to understand the
issue for the client more clearly. The other options are not therapeutic responses
because none of them encourage the client to expand on the concern. Sharing personal
experience takes the discussion off the client and onto the nurse.
A client with disturbed thought processes believes that his food is being poisoned. What
is the most appropriate communication technique by the nurse that would encourage
the client to eat?
1. The use of open-ended questions and silence
2. Discussing personal preference in relation to food choices
3. Recording why the client does not wish to eat
4. Expressing opinions about the need for adequate nutrition - Answer 1. The use of
open-ended questions and silence
Rationale:
,Strategies to get the client talking about their problems include open-ended questions
and silence. Sharing personal food preferences is not a client-centered intervention.
The other options are not supportive of the client because they fail to lead the client into
an expression of feeling. The nurse should not give an opinion and should lead the client
to determine the rationale for the behavior.
A client is admitted to a psychiatric unit for treatment of psychotic behavior. The client
spends hours at the locked exit door shouting, "Let me out. There's nothing wrong with
me. I don't belong here." Which defense mechanism is the client utilizing?
1. Denial
2. Projection
3. Regression
4. Rationalization - Answer 1. Denial
Rationale:
Denial is the refusal to admit to a painful reality, which is treated as if it does not exist.
Projection involves the unconscious rejection of emotionally unacceptable features and
attributing it to other persons, objects, or situations. Regression allows the client to
return to an earlier, more comforting although less mature way of behaving.
Rationalization is justifying illogical or unreasonable ideas, actions, or feelings by
developing acceptable explanations that satisfy the teller and the listener.
A patient with terminal cancer says to the nurse, "I'm going to die, and I wish my family
would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the
one who's dying." Which response by the nurse is therapeutic?
1. "Have you shared your feelings with your family?"
2. "I think we should talk more about your anger with your family."
3. "You're angry feeling your family continues to hope for you to be cured?"
4. "You must be very depressed, which of course is understandable with such a
diagnosis." Response 3. "You're angry feeling your family continues to hope for you to
be cured?"
, Rationale:
Restating is a therapeutic communication technique where the nurse repeats back to
the client what he says to show that he has understood and to review what has been
said. While it is appropriate for the nurse to attempt to assess the client's ability to
discuss feelings openly with family members, it does not help the client discuss the
feelings causing the anger. The nurse's attempt to focus on the central issue of anger is
premature. The nurse would never make a judgment regarding the reason for the
client's feeling; this is nontherapeutic in the one-to-one relationship.
While conducting a review of the client's record, the nurse learns that the client was
voluntarily admitted because of their mental health problem. With this in mind, the nurse
would be able to anticipate which of the following responses the client might give?
1. Fears about the treatment interventions
2. Hostility and aggression towards others
3. Understanding about the pathology and symptoms associated with the diagnosis.
4. A wish to be involved in the planning of the care and treatment plan. -Answer 4. A
wish to be involved in the planning of the care and treatment plan.
Rationale:
Generally speaking, clients request voluntary admissions. In such cases, if a client
requests admission as a volunteer, most likely a client will cooperate with the treatment
program since they are looking for help themselves. The rest of the options are not
characteristics of this type of admission. Fearfulness, anger, and aggressiveness are
more typical for an involuntary admission. Voluntary admission cannot guarantee a
client's understanding of his or her illness, only the understanding of his or her desire
for help.
The nurse is reviewing the admission assessment and finds that this client was admitted
to the mental health unit involuntarily. This type of admission would necessitate that the
nurse implement which of the following interventions for this client?
nimi
1. Closely monitor for harm to self or others.
2. Assist client in completing an application for admission.
