2019 HESI RN MENTAL HEALTH 53 Q & A Graded A

1. When caring for an older client, the nurse observes multiple bruises in over the client’s legs, arms, back, and gluteal areas. When the client contacts, the nurse suspects elder abuse. What action should the nurse? □ Measure and document size, shape and color of the bruised areas. 2. A client who is homeless is diagnosed with schizophrenia and admitted on an involuntary basis to e mental health hospital 4 days ago. The client stopped taking prescribed antipsychotic drugs approximately one month ago. Since hospitalization the client continues to have poor judgment and refuses all medications. What action should the nurse take? □ Administer a long acting antipsychotic medication so that the client can be discharged to a shelter. 3. After receiving treatment for anorexia, a student asks the school nurse for permission to work in the school cafeteria as part of the school’ mpro/hgreamsi. What action should the nurse take? Recommend assignment to the receptionist’s office. 4. A male client comes to the emergency center because he has an erection that will not resolve. The client reports that he is taking trazodone (Desyrel for insomnia. Which information is most important for the nurse to ask this client? □ Have you taken any medication for erectile dysfunction? 5. On admission to the mental health unit, a client diagnosed with schizophrenia tells the nurse that he is the son of God. Based on this statement, which intervention should thenurse include in this client’s plan of care? □ Confront his delusion as not consistent with reality. 6. The nurse on the day shift receives report about a client with depression who wasin bed most of the weekend. The nurse walks into the client’s room in the morning and finds the client in bed. What intervention I best for the nurse to implement? □ Assist the client to get out of bed and involved in an activity. 7. Which client information indicates the need for the n ur seto use the CAGE questionnaire during the admission interview? □ Describes self as a social drinker who drinks alcoholic beverages daily. 8. A female client admitted to the mental health unit stats to shout and scream atthe nurse. What is he best approach for the nurse to take? □ Stay quietly with the client. 9. A woman is brought to the psychiatric clinic by her husband. He reports that his wife is reluctant to leave home because of what she describes as a fear of open places and crows. Which nursing problems applies to the client’s behavior? □ Anxiety related to real or perceived threat to physical integrity. 10. A client is receiving benztropine mesylate (Cogentin) for drug-induced extrapyramidal syndrome (EPS). Which finding indicates that the RN should further evaluate the client? □ Presence of a dry mouth. 11. A male client in the mental health unit is guarded and vaguely answers the nurse’s questions. He isolates in his room and sometimes opens the door to peek into the hall. Which problem can the RN anticipate? □ Delusions of persecution. a b i r b . com/hesi 12. 10. A female client engages in repeated checks of door and window locks, behavior that presents her from arriving on time and interferes with her ability to function effectively. What action should the nurse take? □ Plan a list of activities to be carried out daily. 13. A female client with obsessive compulsive personality disorder is admitted to the hospital for a cardiac catheterization. The afternoon before the procedure, the client begins to keep detailed notes of the nursing care she is receiving, and reports her findings to the RN at bedtime. What action should the nurse implement? □ Encourage the client to express her feelings regarding the upcoming procedure. 14. 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? □ Assist the client in developing alternative coping skills. 15. A female client is brought to the mrtm/heentsaifter 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? □ Acute confusion 16. The occupational health nurse is working with a female employee who was just notified that her 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? □ Call for transportation to the h o sp i t al . 17. A male 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? □ Ineffective sexual patterns. 18. 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 usewhen changing this client’s dressing? □ Perform the dressing change in a non-judgmental manner. 19. 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 tradeplaces, and the RN demonstrates the client’s behaviors. What is the main goal of this therapeutic technique? □ Allow the client to identify the way he interacts. 20. 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? □ Sleep at least 6 hours a night. 21. When preparing to administer to domestic violence screening tool to a female client, which statement should the RN provide? □ All clients are screened for domestic abuse because it is common in our society. 22. 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?