HESI RN MENTAL HEALTH V1

HESI RN MENTAL HEALTH V1 [Document subtitle] HESI RN MENTAL HEALTH V1 1. A client is Prescribed Risperidone (Risperdal) forschizophrenia. Which Side Effects Should the nurse report to the Health Provider? Fever, Tachycardia, Diopheris (sweathing) 2. A homeless women who is well-educated and has chronic schizophrenia is admitted to the mental health unit when found by the police walking in the middle of the street. The client presents with strong body odor, dirty clothes and avoliation. After a week of neurolepticdrug therapy drug therapy, the client discusses with the nurse her thoughts about bathing. Which statement suggest that the client is progressing? I feel good when I take care of myself. 3. A young adult with eroded tooth enamel presents to the clinic with multiple complaints including severe pain in the chest and upper abdomen that occurred when the client induced vomiting after eating a large breakfast. The client also reports severe hearthburn in the last week and describes a history of taking laxatives and eating prunes whenever overeating. What client problem should address first? Erosion of tooth enamel 4. A young adult male receives a prescription for disulfiram to help maintain abstinence from alcohol. What information should the nurse include in a teaching plan for this client? Check labels of OTC drug for alcohol content 5. A older male resident of a long-term care facility who is chronically depressed. Has become more reclusive and refusesto leave hisroom today. Hisfamily moved away from a local area and they are unable to visit as much as they did in the past. Which comment by the nurse is likely to be most helpful to this client? May I sit with you for a while 6. The nurse develops a plan of care for a female client who scratches her wrist in attempt to deal with anxiety. Which client outcome is most important to include in the plan of care. Demonstrates effective ways to cope with anxiety. 7. Aclientwhorecentlyexperiencedthedeathofasignificantotherarivesathemental healthcenter.Theclientreportslosofinterestinusualactivities,expresesawishtobe withthedecreasedsignificantother,hasbeneatingverylitle,andhasnotsleptin severaldays.WhichclientstatementismostimportantfortheRNtoexploreathistime? Not sleeping for several days. 8. An adolescent male client is hospitalized after he threatened a teacher in school. He admits feeling angry because his mother tricked him and brought him tp the hospital . The client steates that when his mother visits, he plans to her his belonging from her, but is not going to talk to her. Which activity is most important for the nurse to complete before the mother arrives? Discuss methods for clearly communicating 9. The charge nurse of the psychiatric unit observes clientsin the day area. Which client is exhibiting symptoms of a conversion disorder? A young women who suddenly goes blind with no indication of organic pathology 10. A client diagnosed with schizophrenia looks frightened and tells the nurse. “ I keep hearing the voicestelling me to hurt somebody. Don’t you hear them? Which response is the best for the nurse to provide? I don’t hear the voices, but you seem very frightened 11. During admissions assessment to the mental health unit, a client reportsthat the people at the office, where the client works, are antagonistic and the client is thinking of the shooting the supervisor. The client asks the nurse not to revel this to anyone else. The nurse immediately notifies the clients therapist and other team members of the client’s thoughts. The therapist then calls the client’s supervisors and shares the client’s thoughts about shooting the supervisors. what outcome is appropriate based on the action of the nurses? The nurse is reprimanded for divulging confidential patient information without obtaining informed consent 12. When implementing a therapeutic on a psychiatric unit, which intervention is most important for the nurse to implement. Encourage client participation in planning weekly activities 13. TheRNurseontheeveningshiftreceivesreporthataclientischeduledfor electroconvulsivetreatment(ECT)inthemorning.WhichinterventionshouldtheRn implementheeveningbeforethescheduledECT? Keep The client NPO after midnight 14. Amaleadultcomestothementalhealthclinicandwalksbackandforthinfrontofthe officedoor,butdoesnotentertheoffice.Hethenwalksaroundachairthatisinthe halwayseveraltimesbeforesitingdowninthechair.Whatactionshouldthenursetake first Observe the client in the Chair 15. Afemaleclientisbroughtotheemergencydepartmentafterpoliceofficersfoundher disoriented,disorganized,andconfused.TheRNalsodeterminesthatheclientis homelesandisexhibitingsuspiciousnes.Theclient’splanofcareshouldincludewhat priorityproblem? Acute confusion 16. Whenassessinga7-year-oldgirl,thenursenotesthatshehasmultiplebruises onherbackanduperarms.Thechild'sauntelsthenursethathechild's parentsabusedrugsandalcohol.Whatinterventionismostessentialforthe nursetoimplement?Assement findings should be reported to the proper legal authorities 17. AmaleclientwithalonghistoryofalcoholdependencyarrivesintheEmergency Departmentdescribingthefelingofbugscrawlingonhisbody.Hisblod pressureis170/102,pulserateis10beats/minute,andblodalcoholevel (BAL)is0mg/(dL).Whichprescriptionshouldthenurseadminister? Lorazepam (Ativan) 18. Aclientonthementalhealthunitisbecomingmoreagitated,shoutingathestali, andpacinginthehalway.WhenaPRNmedicationisofered,theclientrefuses themedicationanddefiantlysitsontheflorinthemidleoftheunithalway. Whatnursinginterventionshouldthenurseimplementfirst? Take other client in the area to the client lounge 19. Amiddle-agedremaleclientwithnopreviouspsychiatrichistoryiseninthemental healthclinicbecauseherfamilydescribesherashavingparanoidthoughts.On asesment,shetelsthenurse“Iwantofindoutwhythesepeoplearestalkingme” whichresponseshouldthenurseprovide? It sounds like this experience id frightening you. 20. FolowinginvolvementinaMVC,amiddleagedadultclientisadmitedtothehospital withmultiplefacialfractures.Theclient’sbloodalcoholevelishighonadmision. WhichPRNprescriptionshouldbeadministerediftheclientbeginstoexhibitsignsand symptomsofdeliriumtremens(DTs)? Lorazepam (Ativan) 2mg IM. 21. A client with borderline personality disorder tells the nurse, "You are the best nurse on the unit! The other nurses don't care about me the way you do." Which response is best for the nurse to provide this client? I am not the best nurse. All the nurses are good. 22. A young adult male who was recently diagnosed with bipolar disorder takes lithium carbonate daily. He is graduating from high school next month, and he tells the school nurse that wantsto live away from home for college. What info is most important for the nurse to provide the client and his family? His serum lithium levels should be routinely evaluated. 23. .AmaleclientelstheRNthathedoesnotwantotaketheatypicalantipsychoticdrug, olanzapine(Zypexa),becauseofthesideefectsheexperiencedwhenhetookthedrugfor ayear.Whichexperienceismostlikelyrelatedtotakingolanzapine? Weight gain of 75 pounds 24. A client is discussing feeling related to recent loss with the nurse. The nurse remains silent when the client says, “ I don’t know how I will gone” wha isthe most likely reason for the nurse’s behavior? Silence allows the client to reflect on what is said 25. A successful businessman presents to the community mental health center caining of sleeplessness and axiety over hisfinancialstatus. What action should the nurse take to assist this client in diminishing his anxiety? Teach him to limit sugar and caffeine intake. 26. The nurse notesthat a client with a history of self-mutilation hasincreased body tension and is pacing in the hallway. Which nursing intervention is most important at thistime Complete a thorough room search to ensure client does not have access to objects that can be used self-harm. 27. The nurse is planning client teaching for a 35-year-old client with early alcoholic cirrhosis. Which self-care measuresshould the nurse emphasize for the client’srecovery Vitamin b and multivitamin 28. TheRNisadmitingamaleclientwhotakelithiumcarbonate(Eskalith)twiceaday. WhichinformationshouldtheRNreportotheHCPimmediately Nausea and vomiting 29. During a high school class on substance abuse, a student tells the group. “ If I tried cocaine, I know I could handle it. I know when to stop.” What response is best for the nurse to provide. Denial of addiction problem is often the response to the behavior. 30. What is the most important goal or a client with major depression who has been receiving an antidepressant medication for two weeks?. Does not attempt to commit suicide. 31. A male client turns over a table in the dayroom of a psychiatric unit and threatens to throw a chair at another client. Which actions is the most important for the nurse to implement. Obtain staff assistance to help diffuse the escalating situation. 32. The nurse is using the cage questionnaire as a screening tool for a client sseeking whelp because his life said he had a drinking problem. What information should the nurse explore indepth with the client based on this screening tool. Effort to cut down, annoyance with questions, guilt, drinking as an “eye opener.” 33. The nurse interacts with a male client who is very depressed and slow to respond to questions. The nurse asks the client to explain how he is feeling, but the client looks down at the table. What action would be best for the nurse to implement? Return at a later time to talk. 34. A male with alcohol dependene is admitted to the hospital with abdominal pain. What it intervention should the nurse implement? Providence a calm, quiet, well-lit environment . 35. An adult female is brought to the emergency center after fainting at work. The nurse completes an assessment of the client and identifies caregiver role strain as a nursing problem. What info best supports this problem. Cares for an older parent and her child 36. AclientwithBulimiaanddepresionwhoistakingphenelzine(Nardil)90mgdailyis admitedtoanacutecarehospitalforuncontroledhypertension.Whatdietarychoices shouldtheRNinstructheclientoavoid? Pepperoni pizza 37. After meeting with health provider, a client who is diagnosed with bipolar disorder screaming and stomping both feeile pacing the hallway What action should the nurse take? accompany the client to a quiet area of the unit 38. A client is admitted to the mental health unit and sit un the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious and resists talking. What action should the nurse implement. Attempt to ask the client simple question 39. A recently widowed middle-aged female client presents to the psychiatric for evaluation and tells the nurse that she has “little to live” she describes one previous suicidal and to help ensure client safety, which action is best for the nurse to implement? Encourage the client to remove the gun from her possess 40. Amaleclientwithknownauditoryhalucinationsbeginstalkingloudlyandgesturing wildlywhileintheunit’sdayroom.Whatactionshouldthenurseimplementfirst? Listen to what the client is saying 41. Aclientwhoisadmitedwithaclosedheadinjuryafteragalhasabloodalcoholevel (BAL)of0.28(28%)andisdifficultoarouse.Whichinterventionduringthefirst6hours folowingadmisionshouldthenurseidentifyasthepriority? Place in a side-lying position with head of bed elevated. 42. A male Native-American client diagnosed with depression is 20 min late for an appointment with the psychiatric nurse is an outpatient clinic. Which action should the nurse take. Use remainder of the time to continue the clients counseling. 43. The nurse is taking history of any young adult who is 5 feet 3 inches tall weights 90 pounds. Which reported finding is most important for the nurse to addressimmediately Absence of menstrual cycle 44. Afemaleclientonapsychiatricunitisweatingprofuselywhileshevigorouslydoes push-upsandthenrunsthelengthofthecoridorseveraltimesbeforecrashinginto furnitureinthesitingroom.Pickingherselfup,shebeginstotoschairsaside,looking foraredonetositin.Whenanotherclientobjectstothedisturbance,theclientshouts,“I amtheboshere.IdowhatIwant.”Whichnursingproblembestsupportsthese observations? Risk for other related violence related to disruptive behavior. 45. On admission to the mental health unit, a client with schizophrenia tellsthe nurse that he is the son of God. Based on this statement ehich intervention should the nurse include in this client’s plan of care. Ensure the clients environment is safe. 46. Which client statement suggest to the nurse that is using a defense mechanism of projection to deal with anxiety relates to admission to a psychiatric unit? I am here because the police thought I was doing something V2 47. Whilecaringforanolderclient,theRNobservesmultiplebruisesOvertheclient’slegs, arms,back,andglutealareas.Whentheclient.Contact,theRNsuspectselderabuse. WhatactionshouldtheRNtake? Measureanddocumentsize,shapeandcolorbruisedarea 48. TheRNisperformingintakeinterviewsatapsychiatricclinic.Afemaleclientwitha knownhistoryofdrugabusereportsthatshehadaheartatackfouryearsago.Useof whichsubstanceplacestheclientathighestriskformyocardialinfarction? Methamphetamine 49. Aclientwhoishomelesisdiagnosedwithschizophreniaandadmitedonaninvoluntary basistoamentalhealthhospital4daysago.Theclientstoppedtakingprescribed antipsychoticdrugsapproximatelyonemonthago.Sincehospitalizationtheclient continuestohavepoorjudgmentandrefusesalmedications.WhatactionshouldtheRN take? Administeralongactingantipsychoticmedicationsothatheclientcanbedischargedtoa shelter. 50. Aftereceivingtreatmentforanorexia,astudentaskstheschoolnurseforpermisionto workintheschoolcafeteriaspartoftheschool’sworkstudyprogram.Whatactionshould thenursetake? Recommendasignmentothereceptionist’soffice. 51. Amaleclientcomestotheemergencycenterhehasanerectionthatwilnoresolvethe clientreportsthatheistakingtrazodone(desyrel)forinsomniawhichinformationismost importantforthenursetoaskthisclient? Haveyoutakenanymedication forerectiledysfunction?” 52. Onadmisiontothementalhealthunit,aclientdiagnosedwithschizophreniatelsthe RNthatheisthesonofgod.Basedonthistatement,whichinterventionshouldtheRN includeinthisclient’splanofcare? Confrontshisdelusionasnotconsistent withreality 53. Thenurseonthedayshiftreceivesreportaboutaclientwithdepresionwhowthe wekend.Thenursewalksintotheclient’sroominthemorningandfindsthewhat interventionisbestforthenursetoimplement? Asisthecliento getoutbedandinvolvedinanactivity 54. WhichclientinformationindicatesthenedfortheRNtouseCAGEquestionnaireduring theadmisioninterview? Describe self associal drinker who drinks alcoholic beverages daily 55. AfemaleclientadmitedtothementalhealthunitstartstoshoutandscreamatheRN. WhatisthebestapproachfortheRNtotake? Stay quietly with the patient. 56. Awomanisbroughtothepsychiatricclinicbyherhusband.Hereportsthathiswifeis reluctantoleavehomebecauseofwhatshedescribesasafearofopenplacesand crowds.Whichnursingproblemappliestothisclient’sbehavior? Anxiety related to real or perceived threat to physical integrity 57. Aclientisreceivingbenztropinemesylate(Cogentin)fordrug-inducedextrapyramidal syndrome(EPS).WhichfindingindicatesthatheRNshouldfurtherevaluatetheclient? Presence of a dry mouth 58. Amaleclientinthementalhealthunitisguardedandvaguelyanswersthenurse’s questions.Heisolatesinhisroomandsometimesopensthedoortopekintothehal. WhichproblemcantheRNanticipate? Delusion of persecution 59. Afemaleclientengagesinrepeatedchecksofdoorandawindowlockbehaviorthat preventsherfromarivingontimeandinterfereswithherabilitytofunctionefectively. Whatactionshouldthenursetake? Plan a list of activities to be carried out daily 60. A female client with obsessive-compulsive disorder is admitted to the hospital for a cardiac catherization. The afternoon before the procedures, the client begins to kepp detailed notes of the nursing care she is receiving, and reports her finding to the nurse at bedtime. What action should the nurse implement. Encourage the client to express her feelings regarding the upcoming procedure 61. 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. Administer a PRN sedative to help relieve anxiety. 62. Afemaleclientisbroughtotheemergencydepartmentafterpoliceofficersfoundher disoriented,disorganized,andconfuse.Thenursealsodeterminesthatheclientis homelesandslightlysuspicious.Thisclient’streatmentplanshouldincludewhatpriority problem? Acute confuse 63. The occupational health nurse is working with a female employee who just notified that her child was involved in a motor vehicle collision and taken to the hospital. The employee states,” I can’t believe this. What should I do? Which response isthe best fo r the nurse to provide in this crisis? Call a transportation to the hospital 64. AclientelstheRNthathehasanIQof400+andisageniusandaninventor.Healso reportsthatheismariedtoafemalemoviestarandthinksthathisbrotherwantsasexual relationshipwithher.Whatistheprioritynursingproblemforadmisiontothe psychiatricunit? Ineffective sexual patterns 65. TheRNisprovidingcareforaclientdiagnosedwithborderlinepersonalitydisorderwho haself-inflictedlacerationsontheabdomen.WhichapproachshouldtheRNusewhen changingthisclient’sdresing? Perform the dressing change in a non-judgmental manner 66. Whilesitinginthedayroomofthementalhealthunit,amaleadolescentavoidseye contact,looksathefloor,andtalksoftlywheninteractingverbalywiththeRN.The twotradeplaces,andtheRNdemonstratestheclient’sbehaviors.Whatisthemaingoal ofthistherapeutictechnique? Alowtheclientoidentifythewayheinteracts. 67. Anantidepresantmedicationisprescribedforaclientwhoreportslepingonly4hours inthepast2daysandweightlosof9lbswithinthelastmonth.Whichclientgoalismost importantoachievewithinthefirsthredaysoftreatment? Sleep at least six hours a night. 68. Whenpreparingtoadministertodomesticviolencescreningtooltoafemaleclient, whichstatementshouldtheRNprovide? All Clients are screened for domestic abuse because it is common in our society. 69. Ayoungadultfemalevisitsthementalhealthcliniccomplainingofdiarhea,headache, andmuscleaches.Sheisafebrile,denieschils,andalaboratoryfindingsarewithin normalimits.DuringthephysicalasesmentheclientelstheRNthathersisterthinks sheisneuroticandcalsherahypochondriac.WhichresponseisbestfortheRNto provide?Besideyoursistercomments,whatinyourlifeistroublingyou. 70. Thenurseisleadinggroupontheinpatientpsychiatricunit.Whichapproachshouldthe nurseuseduringtheworkingphaseinthegroupdevelopment?Helpingclientsidentify areasofproblemintheirlives. 71. Amaleclientwithschizophreniaisdemonstratingecholalia,whichisbecomingannoying tootherclientsontheunit.WhatinterventionisbestfortheRNtoimplement.Escort theclientohisroom. 72. Aclientisadmitedforbipolardisorderandalcoholwithdrawal,depresivephase.Based onwhichasesmentfindingwiltheRNwithholdtheclonidine(Catapres)prescription? A.Bloodpresurereadingsof90/62mmHgto92/58mmHg. 73. TheRNontheeveningshiftreceivesreporthataclientischeduledfor electroconvulsivetreatment(ECT)inthemorning.WhichinterventionshouldtheRn implementheeveningbeforethescheduledECT? Keep the client NPO after midnight 74. AclientwithBulimiaanddepresionwhoistakingphenelzine(Nardil)90mgdailyis admitedtoanacutecarehospitalforuncontroledhypertension.Whatdietarychoices shouldtheRNinstructheclientoavoid? Pepperoni pizza 75. Amentalhealthworkeriscaringforaclientwithescalatingagresivebehavior.Which actionbythementalhealthworkerwarantsimmediateinterventionbytheRN?Is attemptingthephysicalrestraintheclient. 76. Aclientwhorecentlyexperiencedthedeathofasignificantotherarivesathemental healthcenter.Theclientreportslosofinterestinusualactivities,expresesawishtobe withthedecreasedsignificantother,hasbeneatingverylitle,andhasnotsleptin severaldays.WhichclientstatementismostimportantfortheRNtoexploreathistime? Notslepingforseveraldays. 77. .Whendevelopingaplanofcareforaclientadmitedtothepsychiatricunitfolowing aspirationofacausticmaterialrelatedtoasuicideatempt,whichnursingproblemhas thehighestpriority? Ineffective breathing pattern 78. .Whendevelopingaplanofcareforaclientadmitedtothepsychiatricunitfolowing aspirationofacausticmaterialrelatedtoasuicideatempt,whichnursingproblemhas thehighestpriority? Riskforotherrelatedviolencerelatedtodisruptivebehavior 79. ARNispreparingthephysicalenvironmentointerviewanewclientforadmisiontothe mentalhealthunit.Whichenvironmentalsetingfacilitatesthebestoutcomeofthe interview? Reducethenoiselevelintheroombyturningoffthetelevisionandradio. 80. Themotherofan8montholdinfantwithprofoundmentalandphysicaldisabilitiestels thenursehowdepresedsheisbecausesheisbecausesherealizesthatherchilfwilnever achievenormalgrowthanddevelopmentmilestones.Howshouldthenurserespondtothis mother? Askthemotherifshehaseverthoughtaboutharmingherselforchild. 81. Aclientwithschizophreniaisadmitedtothepsychiatriccareunitforagresive behavior,auditoryhalucinations,andpotentialforsafeharm.Theclienthasnotben takingmedicationsasprescribedandinsiststhathefoodhasbenpoisonedandrefuses toeat.WhatinterventionshouldtheRNimplement? Providetheclientwithfoodinunopencontainers. 82. Anurseisprovidingeducationaboutstrategiesforasafetyplanforafemaleclientwhois avictimofintimatepartnerviolence.Whichstrategieshouldbeincludedinthesafety plan?A.Purchaseaguntouseforprotection Establishacodewithfamilyandfriendstosignifyviolence. Plananescaperoutetouseiftheabuserblocksthemainexit. Haveabigreadythathasextraclothesforselfandchildren 83. TheRNisadmitingamaleclientwhotakelithiumcarbonate(Eskalith)twiceaday. WhichinformationshouldtheRNreportotheHCPimmediately? Nausea and vomiting 84. Amaleclientwhoisadmitedwithdeliriumtremensisdehydratedandexperiencing auditoryhalucinations.Hehasabruised,swolentongueandisconfused.Indevelopinga planofcare,whichactionshouldtheRNincludetoensuretheclientisphysiologicaly stable? Monitor Vital Signs. 85. Thenurseisteachingaclientaboutheinitiationofaprescribedabstinencetherapyusing disulfiram(Antabuse).Whatinformationshouldtheclientacknowledgeunderstanding? Remain alcohol free for 12 hours prior the first dose. 86. TheRNisworkingwithamaleclientatacommunitymentalhealthcenterwhenthe clientreportshearingvoicesthatelhimtogetaknifefromthekitchenandhurthimself. WhatinterventionismostimportantfortheRNtoimplement? Assign a UAP to remain with the client all the times 87. Ahomelesclientwhoreportsfelingsadanddepresedtelsthementalhealthnursethat inthepast2dayshehasonlyhad4hoursofslep.Whichactionismostimportantfor theRNtoimplementwithinthefirst24hoursaftertreatmentisinitiated? Allow the client to rest and sleep. 88. WhichclientstatementsugeststheRNthatheclientisusingadefensemechanismof projectiontodealwithanxietyrelatedtoadmisiontoapsychiatricunit I am here because the police though I was doing something wrong 89. Amaleclientisadmitedtothepsychiatricinpatientunitwithabandagedfleshwound afteratemptingtoshoothimself.Hewasdivorcedoneyearago.Losthisjobfourmonths ago,andsuferedabreakupofiscurentrelationshiplastwek.Whatismostlikely sourceofthisclient’scurentfelingsofdepresion? A sense of loss 90. Thenursedocumentsthementalstatusofafemaleclientwhohasbenhospitalizedfor severaldaysbycourtorder.Theclientstate,“Idon’tnedtobehere”andtelsthenurse thatshebelievesthathetelevisiontalkstoher.Thenurseshoulddocumenthese asesmentfindingsinwhichsectionofthementalstatusexam? Insight and judgment 91. Anolderaleclientwithschizophreniaisfoundsmearingfecesnthebathroomwalsof thechronicmentalhealthunitwhereheresides.WhatactionshouldtheRNimplement? Escort the client out of the bathroom 92. Thenursecompleteanasesmentofaclientwhoisexperiencingintimatepartner violence(IPV)whichfindingoftheinjurieshouldthenurseincludeinthe documentation? Photographs