HESI MENTAL HEALTH NEWEST EDITION V1
EXAM QUESTIONS WITH CORRECT DETAILED
ANSWERS ALREADY GRADED A+|STUDY TO
PASS
1. During admission to the psychiatric unit, a female client is extremely anxious and
states that she is worried about the sun coming up the next day. What intervention is
most important for the RN to implement during the admission process? - ANSWERS -
Assist the client in developing alternative coping skills.
2. A female client is brought to the emergency department after police officers found her
disoriented, disorganized, and confused. The RN also determines that the client is
homeless and is exhibiting suspiciousness. The client's plan of care should include what
priority
problem? - ANSWERS -Acute confusion.
The occupational health nurse is working with a female employee who was just notified
thather child was involved in a MVA and taken to the hospital. The employee states, "I
can't believe this. What should I do?" Which response is best for the RN to provide in
this crisis? - ANSWERS -Call for transportation to the hospital.
A client tells the RN that he has an IQ of 400+ and is a genius and an inventor. He also
reports that he is married to a female movie star and thinks that his brother wants a
sexual relationship with her. What is the priority nursing problem for admission to the
psychiatric
unit? - ANSWERS -Ineffective sexual patterns.
The RN is providing care for a client diagnosed with borderline personality disorder who
has self-inflicted lacerations on the abdomen. Which approach should the RN use when
changing this client's dressing? - ANSWERS -Perform the dressing change in a non-
judgmental manner.
While sitting in the day room of the mental health unit, a male adolescent avoids eye
contact, looks at the floor, and talks softly when interacting verbally with the RN. The
two trade places, and the RN demonstrates the client's behaviors. What is the main goal
of this
therapeutic technique? - ANSWERS -Allow the client to identify the way he interacts.
,An antidepressant medication is prescribed for a client who reports sleeping only 4
hours in the past 2 days and weight loss of 9 lbs within the last month. Which client goal
is most important to achieve within the first three days of treatment? - ANSWERS -
Sleep at least 6 hours a night.
When preparing to administer to domestic violence screening tool to a female client,
which statement should the RN provide? - ANSWERS -All clients are screened for
domestic abuse because it is common in our society.
A young adult female visits the mental health clinic complaining of diarrhea, headache,
and
muscle aches. She is afebrile, denies chills, and all laboratory findings are within normal
limits. During the physical assessment, the client tells the RN that her sister thinks she
is neurotic and calls her a hypochondriac. Which response is best for the RN to
provide? - ANSWERS -Besides your sister's comments, what in your life is troubling
you?
The RN is leading a group on the inpatient psychiatric unit. Which approach should the
RN use during the working phase of group development? - ANSWERS -Helping clients
identify areas of problem in their lives.
A male client with schizophrenia is demonstrating echolalia, which is becoming
annoying to other clients on the unit. What intervention is best for the RN to implement?
- ANSWERS -Escort the client to his room.
A client is admitted for bipolar disorder and alcohol withdrawal, depressive phase.
Based on which assessment finding will the RN withhold the clonidine (Catapres)
prescription? - ANSWERS -Blood pressure readings of 90/62 mmHg to 92/58 mmHg.
The RN on the evening shift receives report that a client is scheduled for
electroconvulsive treatment (ECT) in the morning. Which intervention should the Rn
implement the evening
before the scheduled ECT? - ANSWERS -Keep the client NPO after mid-night.
A client with Bulimia and depression who is taking phenelzine (Nardil) 90 mg daily is
admitted to an acute care hospital for uncontrolled hypertension. What dietary choices
should the RN instruct the client to avoid? - ANSWERS -Peperoni pizza.
A mental health worker is caring for a client with escalating aggressive behavior. Which
action by the mental health worker warrants immediate intervention by the RN? -
ANSWERS -Is attempting the physically restrain the patient.
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? - ANSWERS -Not sleeping for several days.
A middle aged adult with major depressive disorder suffers from psychomotor
retardation, hypersomnia, and motivation. Which intervention is likely to be most
effective in returning this client to a normal level of functioning? - ANSWERS -Teach
the client to develop a plan for daily structured activities.
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? - ANSWERS -Ineffective breathing pattern.
A female client on a psychiatric unit is sweating profusely while she vigorously does
pushups 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 to the disturbance, the client shouts,
"I am the boss here. I do what I want." Which nursing problem best supports these
observations? - ANSWERS -Risk for other related violence related to disruptive
behavior.
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? - ANSWERS -Reduce the noise level in the room by turning off the television
and radio.
An older homeless client visits the psychiatric clinic to obtain a prescription renewal for
alprazolam (Xanax). During the health assessment, the client complains of chest pain.
Which action should the RN take first? - ANSWERS -Determine if Xanax was taken
recently.
The mother of an 8-month-old infant with profound mental and physical disabilities tells
he RN how depressed she is because she realized that her child will never achieve
normal growth and development milestones. How should the RN respond to the
mother? - ANSWERS -Ask the mother if she has ever thought about harming herself or
her child.
Several clients with chronic mental illness and multiple substance abuse histories live in
a group residential home and attend daycare mental health facility where group and
individual therapies are provided. The RN finds the common bathroom at the facility with
sputum on the walls, urine in the sink and on the floors, and the toilet stopped up with
tissue, paper towels, and feces. What is the priority issue that the RN should address? -
ANSWERS -Infection control.
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? - ANSWERS -Provide the client with food
in unopened containers.
The RN 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? (SOA) - ANSWERS -B. Establish a code with family and friends to signify
violence.
D. Have a bag ready that has extra clothes for self and children.
E. Plan an escape route to use if the abuser blocks the main exit.
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? - ANSWERS -
Nausea and vomiting.
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? - ANSWERS -Monitor vital signs.
A RN is teaching a client about initiation of a prescribed abstinence therapy using
Disulfiram (Antabuse). What information should the client acknowledge understanding?
- ANSWERS -Remain alcohol free for 12 hours prior to first dose.
The RN is working with a male client at a community mental health center when the
client reports hearing voices that tell him to get a knife from the kitchen and hurt himself.
What intervention is most important for the RN to implement? - ANSWERS -Assign the
UAP to remain with the client at all times.
A homeless client who reports feeling sad and depressed tells the mental health nurse
that in the past 2 days she has only had 4 hours of sleep. Which action is most
important for the RN to implement within the first 24 hours after treatment is initiated? -
ANSWERS -Allow the client to rest and sleep.
Which client statement suggests the RN that the client is using a defense mechanism of
projection to deal with anxiety related to admission to a psychiatric unit? - ANSWERS -I
am here because the police thought I was doing something wrong.
A male client is admitted to the psychiatric inpatient unit with a bandaged flesh wound
after attempting to shoot himself. He was divorced one year ago. Lost his job four
months ago,
and suffered a breakup of is current relationship last week. What is most likely source of
this client's current feelings of depression? - ANSWERS -A sense of loss
EXAM QUESTIONS WITH CORRECT DETAILED
ANSWERS ALREADY GRADED A+|STUDY TO
PASS
1. During admission to the psychiatric unit, a female client is extremely anxious and
states that she is worried about the sun coming up the next day. What intervention is
most important for the RN to implement during the admission process? - ANSWERS -
Assist the client in developing alternative coping skills.
2. A female client is brought to the emergency department after police officers found her
disoriented, disorganized, and confused. The RN also determines that the client is
homeless and is exhibiting suspiciousness. The client's plan of care should include what
priority
problem? - ANSWERS -Acute confusion.
The occupational health nurse is working with a female employee who was just notified
thather child was involved in a MVA and taken to the hospital. The employee states, "I
can't believe this. What should I do?" Which response is best for the RN to provide in
this crisis? - ANSWERS -Call for transportation to the hospital.
A client tells the RN that he has an IQ of 400+ and is a genius and an inventor. He also
reports that he is married to a female movie star and thinks that his brother wants a
sexual relationship with her. What is the priority nursing problem for admission to the
psychiatric
unit? - ANSWERS -Ineffective sexual patterns.
The RN is providing care for a client diagnosed with borderline personality disorder who
has self-inflicted lacerations on the abdomen. Which approach should the RN use when
changing this client's dressing? - ANSWERS -Perform the dressing change in a non-
judgmental manner.
While sitting in the day room of the mental health unit, a male adolescent avoids eye
contact, looks at the floor, and talks softly when interacting verbally with the RN. The
two trade places, and the RN demonstrates the client's behaviors. What is the main goal
of this
therapeutic technique? - ANSWERS -Allow the client to identify the way he interacts.
,An antidepressant medication is prescribed for a client who reports sleeping only 4
hours in the past 2 days and weight loss of 9 lbs within the last month. Which client goal
is most important to achieve within the first three days of treatment? - ANSWERS -
Sleep at least 6 hours a night.
When preparing to administer to domestic violence screening tool to a female client,
which statement should the RN provide? - ANSWERS -All clients are screened for
domestic abuse because it is common in our society.
A young adult female visits the mental health clinic complaining of diarrhea, headache,
and
muscle aches. She is afebrile, denies chills, and all laboratory findings are within normal
limits. During the physical assessment, the client tells the RN that her sister thinks she
is neurotic and calls her a hypochondriac. Which response is best for the RN to
provide? - ANSWERS -Besides your sister's comments, what in your life is troubling
you?
The RN is leading a group on the inpatient psychiatric unit. Which approach should the
RN use during the working phase of group development? - ANSWERS -Helping clients
identify areas of problem in their lives.
A male client with schizophrenia is demonstrating echolalia, which is becoming
annoying to other clients on the unit. What intervention is best for the RN to implement?
- ANSWERS -Escort the client to his room.
A client is admitted for bipolar disorder and alcohol withdrawal, depressive phase.
Based on which assessment finding will the RN withhold the clonidine (Catapres)
prescription? - ANSWERS -Blood pressure readings of 90/62 mmHg to 92/58 mmHg.
The RN on the evening shift receives report that a client is scheduled for
electroconvulsive treatment (ECT) in the morning. Which intervention should the Rn
implement the evening
before the scheduled ECT? - ANSWERS -Keep the client NPO after mid-night.
A client with Bulimia and depression who is taking phenelzine (Nardil) 90 mg daily is
admitted to an acute care hospital for uncontrolled hypertension. What dietary choices
should the RN instruct the client to avoid? - ANSWERS -Peperoni pizza.
A mental health worker is caring for a client with escalating aggressive behavior. Which
action by the mental health worker warrants immediate intervention by the RN? -
ANSWERS -Is attempting the physically restrain the patient.
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? - ANSWERS -Not sleeping for several days.
A middle aged adult with major depressive disorder suffers from psychomotor
retardation, hypersomnia, and motivation. Which intervention is likely to be most
effective in returning this client to a normal level of functioning? - ANSWERS -Teach
the client to develop a plan for daily structured activities.
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? - ANSWERS -Ineffective breathing pattern.
A female client on a psychiatric unit is sweating profusely while she vigorously does
pushups 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 to the disturbance, the client shouts,
"I am the boss here. I do what I want." Which nursing problem best supports these
observations? - ANSWERS -Risk for other related violence related to disruptive
behavior.
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? - ANSWERS -Reduce the noise level in the room by turning off the television
and radio.
An older homeless client visits the psychiatric clinic to obtain a prescription renewal for
alprazolam (Xanax). During the health assessment, the client complains of chest pain.
Which action should the RN take first? - ANSWERS -Determine if Xanax was taken
recently.
The mother of an 8-month-old infant with profound mental and physical disabilities tells
he RN how depressed she is because she realized that her child will never achieve
normal growth and development milestones. How should the RN respond to the
mother? - ANSWERS -Ask the mother if she has ever thought about harming herself or
her child.
Several clients with chronic mental illness and multiple substance abuse histories live in
a group residential home and attend daycare mental health facility where group and
individual therapies are provided. The RN finds the common bathroom at the facility with
sputum on the walls, urine in the sink and on the floors, and the toilet stopped up with
tissue, paper towels, and feces. What is the priority issue that the RN should address? -
ANSWERS -Infection control.
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? - ANSWERS -Provide the client with food
in unopened containers.
The RN 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? (SOA) - ANSWERS -B. Establish a code with family and friends to signify
violence.
D. Have a bag ready that has extra clothes for self and children.
E. Plan an escape route to use if the abuser blocks the main exit.
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? - ANSWERS -
Nausea and vomiting.
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? - ANSWERS -Monitor vital signs.
A RN is teaching a client about initiation of a prescribed abstinence therapy using
Disulfiram (Antabuse). What information should the client acknowledge understanding?
- ANSWERS -Remain alcohol free for 12 hours prior to first dose.
The RN is working with a male client at a community mental health center when the
client reports hearing voices that tell him to get a knife from the kitchen and hurt himself.
What intervention is most important for the RN to implement? - ANSWERS -Assign the
UAP to remain with the client at all times.
A homeless client who reports feeling sad and depressed tells the mental health nurse
that in the past 2 days she has only had 4 hours of sleep. Which action is most
important for the RN to implement within the first 24 hours after treatment is initiated? -
ANSWERS -Allow the client to rest and sleep.
Which client statement suggests the RN that the client is using a defense mechanism of
projection to deal with anxiety related to admission to a psychiatric unit? - ANSWERS -I
am here because the police thought I was doing something wrong.
A male client is admitted to the psychiatric inpatient unit with a bandaged flesh wound
after attempting to shoot himself. He was divorced one year ago. Lost his job four
months ago,
and suffered a breakup of is current relationship last week. What is most likely source of
this client's current feelings of depression? - ANSWERS -A sense of loss
