Psychiatric Mental Health Assignment
Exam Hesi Practice 38
The nurse is caring for an adult male client with catatonic schizophrenia who is mute and
motionless. What is the priority nursing problem?
A. Impaired mobility.
B. Ineffective individual coping.
C. Impaired verbal communication.
D. High risk for fluid and electrolyte imbalance. - ANSWERSANS: D. High risk for fluid and
electrolyte imbalance.
Maintaining physiological stability by first addressing basic physiological needs is the priority. A
client who is in a catatonic or stuporous state is at risk for malnutrition and dehydration. Fluid
and electrolyte imbalance is the priority nursing problem for this client at this time. The other
problems are not life-threatening.
A female client comes to an outpatient therapy appointment intoxicated. The spouse tells the
nurse, "There wasn't anything I could do to stop her drinking this morning." What intervention
should the nurse take at this time?
A. Arrange for emergency admission to a detoxification unit.
B. Talk to the spouse about strategies to limit the client's drinking.
,C. Have the client admitted to the inpatient psychiatric unit.
D. Tell the client that therapy cannot take place while she is intoxicated. - ANSWERSANS: D. Tell
the client that therapy cannot take place while she is intoxicated.
Therapy sessions are designed to confront the issues that the client with alcohol dependence
may be experiencing. If the client presents inebriated, a therapeutic and confrontational
meeting cannot occur because the client's judgment is altered. The other interventions are not
necessary.
Which action is most important for the nurse to implement during the initial interview for a
client who is admitted to the mental health unit?
A. Establish rapport in each phase of the nurse-client relationship.
B. Determine the client's ability to communicate effectively.
C. Reflect on previous psychiatric interviews the nurse has performed.
D. Ensure data is collected and recorded in a systematic sequence. - ANSWERSANS: A. Establish
rapport in each phase of the nurse-client relationship.
A client with whom the nurse establishes rapport during the initial interview and in each phase
of the nurse-client relationship feels understood by the nurse and is more likely to cooperate
and provide feedback during the admission process. The other actions not always needed to
establish rapport or maintain the therapeutic self in a therapeutic relationship.
,The nurse is planning the care for a client based on the psychoanalytical model. Which
intervention should the nurse include in the plan of care?
A. Emphasize the client's strengths and assets.
B. Teach the importance of medication compliance.
C. Offer the client psychoeducational materials to read.
D. Focus on the client's positive or negative feelings toward the nurse. - ANSWERSANS: D. Focus
on the client's positive or negative feelings toward the nurse.
Interactions and interventions that focus on the client's positive or negative feelings toward the
nurse are based on the psychoanalytical model of mental health care. The other interventions
are not associated with the psychoanalytical model.
A client on the mental health unit reports concerns about weight gain as a result of taking
divalproex (Depakote) and requests assistance to fill out a menu. The nurse should initiate a
referral to which healthcare team member?
A. Occupational therapist.
B. Recreational therapist.
C. Dietician.
D. Physician. - ANSWERSANS: C. Dietician.
, The nurse should ask for a referral to the dietician who can assist the client with meal planning
for weight reduction. The other members of the healthcare team do not give guidance about
meal planning.
Which client should the nurse identify as the highest risk for the onset of stress-related
problems?
A. A man whose new business is growing slowly, who plans to adopt a child with his wife, and
says, "I think I'm in control of my destiny."
B. A woman who is graduating from college, getting married in one month, and states, "I'm
anticipating the changes these events will make in my life."
C. A client who is passed over for promotion, quits a job to start a new business, and states,
"This is just one of a series of challenges I've faced in my life."
D. A person whose father died three months ago, who is losing a job due to company
downsizing, and states, "Living with loss and the threat of loss makes me feel helpless." -
ANSWERSANS: D. A person whose father died three months ago, who is losing a job due to
company downsizing, and states, "Living with loss and the threat of loss makes me feel
helpless."
A client who is dealing with two stressful life events and expresses a cognitive appraisal of loss
and helplessness is at the highest risk for a stress-related health problem. The other persons are
coping with change using healthy strategies.
An older client is admitted to a psychiatric hospital with the diagnosis, "Major depression, single
episode." Which laboratory value is most important for the nurse to report to the healthcare
provider immediately?
A. Increased serum creatinine level.
Exam Hesi Practice 38
The nurse is caring for an adult male client with catatonic schizophrenia who is mute and
motionless. What is the priority nursing problem?
A. Impaired mobility.
B. Ineffective individual coping.
C. Impaired verbal communication.
D. High risk for fluid and electrolyte imbalance. - ANSWERSANS: D. High risk for fluid and
electrolyte imbalance.
Maintaining physiological stability by first addressing basic physiological needs is the priority. A
client who is in a catatonic or stuporous state is at risk for malnutrition and dehydration. Fluid
and electrolyte imbalance is the priority nursing problem for this client at this time. The other
problems are not life-threatening.
A female client comes to an outpatient therapy appointment intoxicated. The spouse tells the
nurse, "There wasn't anything I could do to stop her drinking this morning." What intervention
should the nurse take at this time?
A. Arrange for emergency admission to a detoxification unit.
B. Talk to the spouse about strategies to limit the client's drinking.
,C. Have the client admitted to the inpatient psychiatric unit.
D. Tell the client that therapy cannot take place while she is intoxicated. - ANSWERSANS: D. Tell
the client that therapy cannot take place while she is intoxicated.
Therapy sessions are designed to confront the issues that the client with alcohol dependence
may be experiencing. If the client presents inebriated, a therapeutic and confrontational
meeting cannot occur because the client's judgment is altered. The other interventions are not
necessary.
Which action is most important for the nurse to implement during the initial interview for a
client who is admitted to the mental health unit?
A. Establish rapport in each phase of the nurse-client relationship.
B. Determine the client's ability to communicate effectively.
C. Reflect on previous psychiatric interviews the nurse has performed.
D. Ensure data is collected and recorded in a systematic sequence. - ANSWERSANS: A. Establish
rapport in each phase of the nurse-client relationship.
A client with whom the nurse establishes rapport during the initial interview and in each phase
of the nurse-client relationship feels understood by the nurse and is more likely to cooperate
and provide feedback during the admission process. The other actions not always needed to
establish rapport or maintain the therapeutic self in a therapeutic relationship.
,The nurse is planning the care for a client based on the psychoanalytical model. Which
intervention should the nurse include in the plan of care?
A. Emphasize the client's strengths and assets.
B. Teach the importance of medication compliance.
C. Offer the client psychoeducational materials to read.
D. Focus on the client's positive or negative feelings toward the nurse. - ANSWERSANS: D. Focus
on the client's positive or negative feelings toward the nurse.
Interactions and interventions that focus on the client's positive or negative feelings toward the
nurse are based on the psychoanalytical model of mental health care. The other interventions
are not associated with the psychoanalytical model.
A client on the mental health unit reports concerns about weight gain as a result of taking
divalproex (Depakote) and requests assistance to fill out a menu. The nurse should initiate a
referral to which healthcare team member?
A. Occupational therapist.
B. Recreational therapist.
C. Dietician.
D. Physician. - ANSWERSANS: C. Dietician.
, The nurse should ask for a referral to the dietician who can assist the client with meal planning
for weight reduction. The other members of the healthcare team do not give guidance about
meal planning.
Which client should the nurse identify as the highest risk for the onset of stress-related
problems?
A. A man whose new business is growing slowly, who plans to adopt a child with his wife, and
says, "I think I'm in control of my destiny."
B. A woman who is graduating from college, getting married in one month, and states, "I'm
anticipating the changes these events will make in my life."
C. A client who is passed over for promotion, quits a job to start a new business, and states,
"This is just one of a series of challenges I've faced in my life."
D. A person whose father died three months ago, who is losing a job due to company
downsizing, and states, "Living with loss and the threat of loss makes me feel helpless." -
ANSWERSANS: D. A person whose father died three months ago, who is losing a job due to
company downsizing, and states, "Living with loss and the threat of loss makes me feel
helpless."
A client who is dealing with two stressful life events and expresses a cognitive appraisal of loss
and helplessness is at the highest risk for a stress-related health problem. The other persons are
coping with change using healthy strategies.
An older client is admitted to a psychiatric hospital with the diagnosis, "Major depression, single
episode." Which laboratory value is most important for the nurse to report to the healthcare
provider immediately?
A. Increased serum creatinine level.
