PSYCHIATRIC - HESI : PN
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1. An adult client who is withdrawing from alcohol is observed carrying on a
conversation in an empty room while looking under the bed trying to find a
neighbor. What interventions should the practical nurse (PN) implement?
(Arrange the items in order, with first on top and last on bottom.)
A) Take the client's vital signs.
B) Review the last medications administered.
C) Sit quietly with the client.
D) Report the client's behavior to the charge nurse.
E) Administer prn chlordiazepoxide.:
2. The spouse of a client who has been physically abused refuses to leave the
client's room during the admission interview. Which action should the practical
nurse (PN) implement?
A) Conduct the assessment with the spouse in the room.
B) Physically escort the spouse out of the client's room.
C) Wait until the spouse leaves the room to assess the client.
D) Assist the client to walk to a treatment room on the unit.: D) Assist the client to walk
to a treatment room on the unit.
Rationale:
Escorting the client to a treatment room provides the privacy needed to examine her and talk to her without the spouse
in the room. The client may be reluctant to tell the truth with the abusive spouse in the room.
(D)
3. A client with schizophrenia tells the nurse, "Cannot you hear that buzzing
sound? It's the sound CNN makes when it's putting bad thoughts in my head."
Which is the most appropriate response to make to this client?
A) "I will close the door to your room so you can think of something else."
B) "I will need to report that you are still having those hallucinations."
, PSYCHIATRIC - HESI : PN
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C) "I do not hear any buzzing sounds. You are safe here in the hospital."
D) "I do not understand why CNN would choose you for their bad thoughts.": D)
"I do not understand why CNN would choose you for their bad thoughts."
Rationale:
The nurse needs to stress reality by informing the client that the nurse does not hear any buzzing thoughts. The nurse
also needs to help the client feel safe and supported when they are experiencing hallucinations. The nurse should not
leave the client to think of something else. The client is hearing sounds that seem very realistic. The nurse should not
threaten the client (Option B) or argue with the client (Option D).
(D)
4. Several days after hospitalization, a client is repeatedly washing the top of the
same table. Which intervention should the practical nurse (PN) to implement
first to help the client cope with anxiety related to this behavior?
A) Administer a prescribed PRN antianxiety medication.
B) Assist the client to identify stimuli that precipitate the ritualistic activity.
C) Allow time for the ritualistic behavior, and then redirect the client to other
activities.
D) Teach the client relaxation and thought-stopping techniques.: C) Allow time for the
ritualistic behavior, and then redirect the client to other activities.
Rationale:
Initially, the PN should allow time for the ritual to diminish anxiety.
(C)
5. The nurse is caring for a client diagnosed with a bipolar disorder who is acting
aggressively toward others. Which activity should the nurse consider for the
client?
A) Volleyball
, PSYCHIATRIC - HESI : PN
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B) Table tennis
C) Board games
D) Finger painting: D) Finger painting
Rationale:
The client demonstrating aggressive behavior should be directed toward solitary activities that require little attention
span and physical exertion, such as finger painting.
(D)
6. A female client tells the nurse, "sometimes I wish I could go to sleep and not
wake up." The client reports suicidal thoughts when questioned by the practical
nurse (PN). Which action is most important for the PN to take?
A) Assess the client's history for previous suicide attempts.
B) Determine if the client has a plan for committing suicide.
C) Implement one-on-one observation immediately.
D) Provide the client with a "No suicide" contract.: A) Assess the client's history for previous
suicide attempts.
Rationale:
The PN should determine the client's risk for self-harm by asking if a plan for suicide exists which increases the intention
of implementing suicide.
(B)
7. The nurse working in the community health clinic is assessing risk factors that
can decrease medication effectiveness for clients diagnosed with schizophre-
nia. Which client behavior is likely to decrease the effectiveness of psychotropic
medications?
A) Smokes at least 20 cigarettes daily.
B) Misses a medication appointment at the clinic.
C) Hears voices more often than usual.
D) Takes a morning medication later in the day.: A) Smokes at least 20 cigarettes daily.
, PSYCHIATRIC - HESI : PN
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Rationale:
Smoking more than 10 cigarettes daily and drinking more than 250 mg of caffeine can decrease the effectiveness of
antipsychotic and antianxiety medications.
(A)
8. Which client requires the most immediate intervention by the practical
nurse?
A) Client expressing inability to do anything worthwhile
B) Client experiencing sudden onset of confusion and disorientation
C) Client unable to correctly demonstrate changing a dressing
D) Client with T score of −2.5 on a bone density test: B) Client experiencing sudden onset of
confusion and disorientation
Rationale:
Disorientation and confusion are indicative of delirium and requires prompt intervention to maintain client safety,
prevent injury as well as treatment to prevent permanent damage.
(B)
9. During an admission interview, a client reports using alcohol and other illegal
drugs every day for the last 3 years. What question is most important for the
practical nurse (PN) to ask this client?
A) "What happened to make you decide to get help?"
B) "When did you last use alcohol or any other drug?"
C) "Have you ever had any withdrawal symptoms?"
D) "Do you have anyone to help you stay clean?": B) "When did you last use alcohol or any
other drug?"
Study online at https://quizlet.com/_aaj1f9
1. An adult client who is withdrawing from alcohol is observed carrying on a
conversation in an empty room while looking under the bed trying to find a
neighbor. What interventions should the practical nurse (PN) implement?
(Arrange the items in order, with first on top and last on bottom.)
A) Take the client's vital signs.
B) Review the last medications administered.
C) Sit quietly with the client.
D) Report the client's behavior to the charge nurse.
E) Administer prn chlordiazepoxide.:
2. The spouse of a client who has been physically abused refuses to leave the
client's room during the admission interview. Which action should the practical
nurse (PN) implement?
A) Conduct the assessment with the spouse in the room.
B) Physically escort the spouse out of the client's room.
C) Wait until the spouse leaves the room to assess the client.
D) Assist the client to walk to a treatment room on the unit.: D) Assist the client to walk
to a treatment room on the unit.
Rationale:
Escorting the client to a treatment room provides the privacy needed to examine her and talk to her without the spouse
in the room. The client may be reluctant to tell the truth with the abusive spouse in the room.
(D)
3. A client with schizophrenia tells the nurse, "Cannot you hear that buzzing
sound? It's the sound CNN makes when it's putting bad thoughts in my head."
Which is the most appropriate response to make to this client?
A) "I will close the door to your room so you can think of something else."
B) "I will need to report that you are still having those hallucinations."
, PSYCHIATRIC - HESI : PN
Study online at https://quizlet.com/_aaj1f9
C) "I do not hear any buzzing sounds. You are safe here in the hospital."
D) "I do not understand why CNN would choose you for their bad thoughts.": D)
"I do not understand why CNN would choose you for their bad thoughts."
Rationale:
The nurse needs to stress reality by informing the client that the nurse does not hear any buzzing thoughts. The nurse
also needs to help the client feel safe and supported when they are experiencing hallucinations. The nurse should not
leave the client to think of something else. The client is hearing sounds that seem very realistic. The nurse should not
threaten the client (Option B) or argue with the client (Option D).
(D)
4. Several days after hospitalization, a client is repeatedly washing the top of the
same table. Which intervention should the practical nurse (PN) to implement
first to help the client cope with anxiety related to this behavior?
A) Administer a prescribed PRN antianxiety medication.
B) Assist the client to identify stimuli that precipitate the ritualistic activity.
C) Allow time for the ritualistic behavior, and then redirect the client to other
activities.
D) Teach the client relaxation and thought-stopping techniques.: C) Allow time for the
ritualistic behavior, and then redirect the client to other activities.
Rationale:
Initially, the PN should allow time for the ritual to diminish anxiety.
(C)
5. The nurse is caring for a client diagnosed with a bipolar disorder who is acting
aggressively toward others. Which activity should the nurse consider for the
client?
A) Volleyball
, PSYCHIATRIC - HESI : PN
Study online at https://quizlet.com/_aaj1f9
B) Table tennis
C) Board games
D) Finger painting: D) Finger painting
Rationale:
The client demonstrating aggressive behavior should be directed toward solitary activities that require little attention
span and physical exertion, such as finger painting.
(D)
6. A female client tells the nurse, "sometimes I wish I could go to sleep and not
wake up." The client reports suicidal thoughts when questioned by the practical
nurse (PN). Which action is most important for the PN to take?
A) Assess the client's history for previous suicide attempts.
B) Determine if the client has a plan for committing suicide.
C) Implement one-on-one observation immediately.
D) Provide the client with a "No suicide" contract.: A) Assess the client's history for previous
suicide attempts.
Rationale:
The PN should determine the client's risk for self-harm by asking if a plan for suicide exists which increases the intention
of implementing suicide.
(B)
7. The nurse working in the community health clinic is assessing risk factors that
can decrease medication effectiveness for clients diagnosed with schizophre-
nia. Which client behavior is likely to decrease the effectiveness of psychotropic
medications?
A) Smokes at least 20 cigarettes daily.
B) Misses a medication appointment at the clinic.
C) Hears voices more often than usual.
D) Takes a morning medication later in the day.: A) Smokes at least 20 cigarettes daily.
, PSYCHIATRIC - HESI : PN
Study online at https://quizlet.com/_aaj1f9
Rationale:
Smoking more than 10 cigarettes daily and drinking more than 250 mg of caffeine can decrease the effectiveness of
antipsychotic and antianxiety medications.
(A)
8. Which client requires the most immediate intervention by the practical
nurse?
A) Client expressing inability to do anything worthwhile
B) Client experiencing sudden onset of confusion and disorientation
C) Client unable to correctly demonstrate changing a dressing
D) Client with T score of −2.5 on a bone density test: B) Client experiencing sudden onset of
confusion and disorientation
Rationale:
Disorientation and confusion are indicative of delirium and requires prompt intervention to maintain client safety,
prevent injury as well as treatment to prevent permanent damage.
(B)
9. During an admission interview, a client reports using alcohol and other illegal
drugs every day for the last 3 years. What question is most important for the
practical nurse (PN) to ask this client?
A) "What happened to make you decide to get help?"
B) "When did you last use alcohol or any other drug?"
C) "Have you ever had any withdrawal symptoms?"
D) "Do you have anyone to help you stay clean?": B) "When did you last use alcohol or any
other drug?"
