Mental Health PN Hesi Specialty V1

2017 Mental Health PN Hesi Specialty V1. The LPN/LVN calls security and has physical restrains applied when a client who was admitted voluntarily becomes both physically and verbally abusive while demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions? Select all that apply. 1) Libel 2) Battery 3) Assault 4) Slander 5) False Imprisonment Correct Answer: 2) Battery 3) Assault 5) False Imprisonment 2) A nurse is working with a client who has sought counseling after trying to rescue a neighbor involved in a house fire. Despite the client's efforts, the neighbor died. Which action does the nurse engage in with the client during the working phase of the nurse-client relationship? 1) Exploring the client's ability to function 2) Exploring the client's potential for self-harm 3) Inquiring about the client's perception of appraisal of the neighbor's death 4) Inquiring about and examine the client's feelings that may block adaptive coping Correct Answer:4) Inquiring about and examine the client's feelings that may block adaptive coping 3) A client who has just been sexually assaulted is calm and quiet. The nurse analyzes this behavior as indicating which defense mechanism? 1) Denial 2) Projection 3) Rationalization 4) Intellectualization Correct Answer:1) Denial 4) Unresolved feelings related to loss most likely may be recognized during which phase of the therapeutic nurse-client relationship? 1) Working 2) Trusting 3) Orientation 4) Termination Correct Answer: 4) Termination 5) Which statement demonstrates the best understanding of the nurse's role regarding ensuring that each client's rights are respected? 1) "Autonomy is the fundamental right of each and every client." 2) "A client's rights are guaranteed by both state and federal laws." 3) "Being respectful and concerned will ensure that I'm attentive to my clients' rights." 4) "Regardless of the client's condition, all nurses have the duty to respect client rights." Correct Answer: 3) "Being respectful and concerned will ensure that I'm attentive to my clients' rights." 6) A LPN/LVN employed in a mental health unit of a hospital is the leader of a group psychotherapy session. The nurses's role in the termination stage of group development is to: 1) Encourage problem solving 2) Encourage accomplishment of the group's work 3) Acknowledge the contributions of each group member 4) Encourage members to become acquainted with one another Correct Answer: 3) Acknowledge the contributions of each group member 7) A male client with delirium becomes disoriented and confused in his room at night. The best initial nursing intervention is to: 1) Move the client next to the nurse's station 2) Use an indirect light source and turn off the television 3) Keep the television and a soft light on during the night 4) Play soft music during the night, and maintain a well-lit room 2) Use an indirect light source and turn off the television 8) A client is admitted to a medical nursing unit with a diagnosis of acute blindness. Many tests are performed, and there seems to be no organic reason why this client cannot see. The client became blind after witnessing a hit-and-run car accident, when a family of three was killed. A LPN/LVN suspects that the client may be experiencing a: 1) Psychosis 2) Repression 3) Conversion Disorder 4) Dissociative Disorder Correct Answer: 3) Conversion Disorder 9) A manic client announces to everyone in the day room that a stripper is coming to perform this evening. When a nurse firmly states that this is inappropriate and will not happen, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, the LPN/LVN determines that the appropriate action would be to: 1) Orient the client to time, person, and place 2) Tell the client that the behavior is inappropriate 3) Escort the manic client to her room, with assistance 4) Tell the client that smoking privileges are revoked for 24 hours Correct Answer: 3) Escort the manic client to her room, with assistance 10) A LPN/LVN observes that a client is pacing, agitated, and presenting aggressive gestures. The client's speech pattern is rapid, and affect is belligerent. Based on these observations, the nurse's immediate priority of care is to: 1) Provide safety for the client and other clients on the unit 2) Provide the clients on the unit with a sense of comfort and safety 3) Assist the staff in caring for the client in a controlled environment 4) Offer the client a less stimulated area to calm down and gain control Correct Answer: 1) Provide safety for the client and other clients on the unit 11) Select the nursing interventions for a hospitalized client with mania who is exhibiting manipulative behavior. Select all that apply. 1) Communicate expected behaviors to the client 2) Ensure that the client knows that he or she is not in charge of the nursing unit 3) Assist the client in identifying ways of setting limits on personal behaviors 4) Follow through about the consequences of behavior in a non punitive manner 5) Enforce rules and inform the client that he or she will not be allowed to attend therapy groups 6) Be clear with the client regarding the consequences of exceeding limits that have been set regarding behavior Correct Answer: 1) Communicate expected behaviors to the client 3) Assist the client in identifying ways of setting limits on personal behaviors 4) Follow through about the consequences of behavior in a non punitive manner 6) Be clear with the client regarding the consequences of exceeding limits that have been set regarding behavior 12) A nurse determines that the wife of an alcoholic client is benefitting from attending an Al-Anon group when the nurse hears the wife say: 1) "I no longer feel that I deserve the meetings my husband inflicts on me." 2) "My attendance at the meetings has helped me to see that I provoke my husbands violence." 3) "I enjoy attending the meetings because they get me out of the house and away from my husband." 4) "I can tolerate my husband's destructive behaviors now that I know they are common with alcoholics." Correct Answer: 1) "I no longer feel that I deserve the meetings my husband inflicts on me." 13) An LPN/LVN is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse determines that this type of crisis is caused by: 1) Witnessing a murder 2) The death of a loved one 3) A fire that destroyed the client's home 4) A recent rape episode experienced by the client Correct Answer: 2) The death of a loved one 14) An LPN/LVN is conducting an initial assessment on a client in crisis. When assessing the client's perception of the precipitating event that lead to the crisis, the appropriate question to ask is: 1) "With whom do you live?" 2) "Who is available to help you?" 3) "What leads you to seek help now?" 4) "What do you usually do to feel better?" Correct Answer: 3) "What leads you to seek help now?" 15) A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to a nurse "I'm finally cured." The LPN/LVN interprets this behavior as a cue to modify the treatment plan by: 1) Suggesting a reduction of medication 2) Allowing increased "in-room" activities 3) Increasing the level of suicide precautions 4) Allowing the client off-unit privileges as needed Correct Answer: 3) Increasing the level of suicide precautions 16) An emergency department nurse is caring for an adult client who is a victim of family violence. Which priority instruction would be included in the discharge instructions? 1) Information regarding shelters 2) Instructions regarding calling the police 3) Instructions regarding self-defense classes 4) Explaining the importance of leaving the violent situation Correct Answer: 1) Information regarding shelters 17) A female victim of sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. The appropriate nursing response is which of the following? 1) "You need to try and be realistic. The rape did not just occur." 2) "It will take some time to get over these feelings about your rape." 3) "Tell me more about the incident that causes you to feel like the rape just occurred." 4) "What do you think that you can do to alleviate some of your fears about being raped again?" Correct Answer: 3) "Tell me more about the incident that causes you to feel like the rape just occurred." 18) A LPN/LVN is preparing to care for a dying client, and several family members are at the client' bedside. Select the therapeutic techniques that the nurse would use when communicating with the family. Select all that apply. 1) Discourage reminiscing 2) Make decisions for the family 3) Encourage expression of feelings, concerns, and fears 4) Explain everything that is happening to all family members 5) Touch and hold the client's or family member's hands if appropriate 6) Be honest and let the client and family know that they will not be abandoned by the nurse Correct Answer: 3) Encourage expression of feelings, concerns, and fears 5) Touch and hold the client's or family member's hands if appropriate 6) Be honest and let the client and family know that they will not be abandoned by the nurse 19) A client's medication sheet contains a prescription for sertraline (Zoloft). To ensure safe administration of the medication, a nurse would administer the dose: 1) On an empty stomach 2) At the same time each evening 3) Evenly spaced around the clock 4) As needed when the client complains of depression Correct Answer: 2) At the same time each evening 20) A LPN/LVN is preforming a follow-up teaching session with a client discharged 1 month ago. The client is taking fluoxetine (Prozac). What information would be important for the nurse to obtain during this client visit regarding the side effects of the medication? 1) Cardiovascular symptoms 2) Gastrointestinal dysfunctions 3) Problems with mouth dryness 4) Problems with excessive sweating Correct Answer: 2) Gastrointestinal dysfunctions 21) A LVN/LPN is caring for a client with anorexia nervosa. The nurse is monitoring the behavior of the client and understands that a client with anorexia nervosa manages anxiety by: 1) Engaging in immoral acts 2) Always reinforcing self-approval 3) Observing rigid rules and regulations 4) Having the need always to make the right decision Correct Answer: 3) Observing rigid rules and regulations