HESI RN MENTAL HEALTH QUESTIONS & ANSWERS 2023 UPDATE

 A patient who has been on an antidepressant for 2 weeks. What should you watch for?  Correct Answer: suicidal attempts  patient states "I can't get my thoughts together I should really sell my car. It's not in here. Let's buy a car. What is the patient experiencing?  Correct Answer: Tangential thinking  A patient won't take oral meds that is going through alcohol withdrawal. The nurse starts giving saline lock per alcohol protocol and thiamine. What do you tell them that it will help with recovery?  Correct Answer: Thiamine will replenish alcohol effects on the body (something to do with iron)  A nurse visits a community half way house with one bathroom. The nurse notices urine all over the walls of the bathroom. The toilet is clogged with feces and paper towels.  Correct Answer: Infection control.  Older man who recently got divorced and is 2 years sober, and an alcoholic loves God. He loves kids also. What should nurse ask at his initial interaction?  Correct Answer: What is troubling you most.  Schizophrenic patient returns to clinic 2 weeks after receiving dose of Haldol; important info for the nurse to obtain during this visit  Correct Answer: Current vital signs  Chronically depressed older male client of a long-term care facility becomes more reclusive and today refuses to leave room:  Correct Answer: May I sit with for you a while  The nurse is assessing a client with postpartum depression for changes in the Sign & Symptoms that are consistent with postpartum depression? Select all that apply  Correct Answer: Disturbed sleep  Sadness  Poor concentration  A sales executive presents to the psychiatric office for an initial evaluation and tells the nurse "My therapist said my wife was having an affair. I had drinking problem for years, but I have been sober for 3 years. I believe in God What response is best for the nurse to provide?  Correct Answer: What is troubling you the most?  The nurse is taking the history of a young adult female who is 5 feet 4 inches tall and weighs. What is the most important for the nurse to address immediately?  Correct Answer: Intermittent palpitations  A young woman is preparing to be discharged from the psychiatric unit. Which nursing intervention is most important for the nurse to include in this phase of the nurse client relationship:  Correct Answer: Explore the client's feelings related to discharge  a client is being discharged with a prescription of paroxetine. which in traction is most important for the nurse to include in this client's discharge?  Correct Answer: Avoid alcohol  client sitting in corner of day room during admission assessment, what nursing action  Correct Answer: ask client simple questions  Patient who had generalized anxiety disorder is on Alprazolam for a long-term. What is the outcome?  Correct Answer: Importance of not quickly stopping the drug  male client admitted depression and self-mutilation  Correct Answer: Ask if the client has a plan to harm himself  male employee says I'm going to shoot a coworker  Correct Answer: Find out if he has a weapon  Assessing male client with paranoia, which behavior can this client be expected to exhibit  Correct Answer: Is openly hostile towards others for no apparent reason  A client is discussing feelings related to a recent loss with the nurse. The nurse remains silent  Correct Answer: Silence is reflecting the client's sadness  A client who is admitted to the substance abuse center reports having nightmares  Correct Answer: Provide a dark, quiet, and comfortable atmosphere  During the initial nursing interview. "sometimes my thoughts go so fast"  Correct Answer: Exhibits Tangential thinking  A female client with a history of drinking who was admitted 8 hours ago after receiving treatment for minor abrasions occurred from a fall at home. The nurse determines the client's blood alcohol level (BAL) was not analyzed on administration action should the nurse take?  Correct Answer: Ask client about alcohol quantity, frequency, and time of last drink.  A male client is admitted to the psychiatric inpatient unit with a bandaged flesh wound after attempting to shoot himself. he is recently divorced one year ago, lost his job four months ago, and suffered a break up of his current relationship last week. What is the most likely source of this client's current feelings of depression?  Correct Answer: A sense of loss  What is the most important goal for a client diagnosed with major depression who has been receiving an antidepressant medication for two weeks?  Correct Answer: Not attempt to commit suicide  A male adult comes to the mental health clinic and walks back and forth in front of the office door, but does not enter the office. He then walks around a chair that is in the hallway several times before sitting down in the chair. What action should the nurse take first  Correct Answer: Observe the client in the chair  A male client in the mental health unit is guarded and vaguely answers the nurse's questions. He isolates to his room and sometimes opens the door to peek into the hall. Which problem can the nurse anticipate?  Correct Answer: Delusions of persecution  A male client who is seen in the mental health clinic monthly reports feeling very stressed and nervous and further describes becoming angry increasingly more often during the last month. What action should the nurse take first?  Correct Answer: Ask the client to identify problems that have occurred during the last month  A young woman is preparing to be discharged from the psychiatric unit. Which nursing intervention is most important for the nurse to include in this phase of the nurse client relationship?  Correct Answer: Explore the client's feelings related to discharge  A female high school teacher who was a child of alcoholic parents seeks counseling at the community health clinic because of depression over a student who was killed by a drunk driver. After several weeks of counseling, which behavior is the best indicator that the client is coping well with the anxiety related to the student's death?  Correct Answer: Becomes the faculty sponsor for students against drunk driving (SADD)  A male client arrives at the mental health clinic and asks the nurse for more lithium and the antidepressant (Elavil) that he uses to help him sleep. After reviewing his assessment findings with the healthcare provider, a serum creatinine is obtained. What information supports the reason for this laboratory test?  Correct Answer: Lithium is excreted by the kidneys and creatinine is related to kidney functioning  A client with schizophrenia who is taking Haldol begins exhibiting tremors of the extremities. Which intervention should the nurse implement?  Correct Answer: Consult with the healthcare provider about reducing the dosage 31. one on one session and nurse begins to get angry at patient  Correct Answer: Terminate session  Common side effects of anti-depressants (Select all that apply) Correct Answer: Dry mouth Constipation Blurred vision  A woman who started chemotherapy three days ago for cancer of the breast calls the clinic reporting that she is so upset she cannot sleep. The client has several PRN medications available. Which drug should the nurse instruct her to take?  Correct Answer: Lorazepam (Ativan) 8 mg PO HS  When a male client is asked about his reason for coming to the mental health clinic he replies, "It all started because I work in a hostile work environment. My boss would not let me go to a religious service, so I went to human resources, and they didn't want to do anything. It has been a really difficult time for me." Which response should the nurse provide?  Correct Answer: "Have the feelings associated with these events brought you to the clinic?"  A client with a history of chronic alcohol abuse... what other medical condition to suspect  Correct Answer: Pancreatitis  Aspiration due to caustic material related to suicide attempt.  Correct Answer: Ineffective Breathing Pattern  A client with paranoia is admitted to the mental health unit and immediately goes to the corner of the room and sits quietly without communicating. In approaching the client, what intervention should the nurse implement first?  Correct Answer: Explain the nurse's role to the client  A client comes out dressed in short skirt, low top, bright red lipstick.. what should the nurse do  Correct Answer: Assist the client back to their room and help pick out appropriate clothing  A client comes in and is 5'5, 75lbs.. what should the nurse do  Correct Answer: Start an IV for IV resuscitation  A child states "My dad used to drink a beer a day, now he drinks at least a six-pack a day." What can the nurse determine from this statement?  Correct Answer: The parent is exhibiting tolerance to alcohol  2 days after admission from alcohol withdrawal what should the nurse do? A) Correct Answer: Monitor HR and BP  Teen in ER for threatening teacher. what interventions should the nurse implement? A) Correct Answer: Methods of clearly communicating  Patient says, "I'm going to shoot myself" B) Correct Answer: Stop the client from leaving the unit  History of alcoholism admitted for detoxification; 6mg of Ativan what additional prescription administer immediately C) Correct Answer: Vitamin B1(thiamine)  PTSD admitted to psychiatric unit, which intervention is most important for plan of care A) Correct Answer: Provide a quiet rook, away from the recreational area  Chronically depressed older male client of a long-term care facility becomes more reclusive and today refuses to leave room B) Correct Answer: May I sit with for you a while  Male client on atypical antipsychotic drug olanzapine(Zyprexa) A) Correct Answer: Adverse reaction is weight gain  A client with depression remains in bed most of the day, declines activities and refuses meals. Which nursing problem has the greatest priority for this client? a. Loss of interest in diversional activity. b. Social isolation c. Refusal to address nutritional needs d. Low self-esteem.  The nurse is preparing medications for a client with bipolar disorder and notices that the antipsychotic medication was discontinued several days ago. Which medication should also be discontinued? a. Lithium (lithotabs ) b. Benztropine (Cogentin) c. Alprazolam (Xanax) d. Magnesium (milk of magnesia)  A female client request that her husband be allowed to stay in the room during the admission assessment. While interviewing the client, the nurse notes a discrepancy between the client’s verbal and nonverbal communication. What action should the nurse take? a. Pay close attention and document the nonverbal messages b. Ask the client’s husband to interpret the discrepancy c. Ignore the nonverbal behavior and focus on the client’s verbal messages. d. Integrate the verbal and nonverbal messages and interpret them as one.  A male client approaches the nurse with an angry expression on his face and raises his voice, saying, “My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out!” the nurse recognizes that the client is using which defense mechanism? a. Denial b. Projection c. Rationalization d. Splitting  A male client with bipolar disorder who began taking lithium carbonate five days ago is complaining of excessive thirst, and the nurse finds him attempting to drink water from the bathroom sink faucet. Which intervention should the nurse implement? a. Report the client’s serum lithium level to the healthcare provider b. Encourage the client to suck on hard candy to relieve the symptoms c. No actions is needed since polydipsia is a common side effect d. Tell the client that drinking from the faucet is not allowed  The nurse is teaching a client about the initiation of a prescribed abstinence therapy using disulfiram (Antabuse). What information should the client acknowledge understanding? a. Completely abstain from heroin or cocaine use b. Remain alcohol free from 12 hours prior to the first dose c. Attend monthly meetings of alcoholics anonymous d. Admit to others that he is a substance abuser  A male client with schizophrenia is admitted to the mental health unit after abruptly stopping his prescription for ziprasidone (Geodon) one month ago. Which question is most important for the nurse to ask the client a. Have you lost interest in the things that you used to enjoy? b. Is your ability to think or concentrate decreased? c. How many continuous hours do you sleep at night d. Do you hear sounds or voices that others do not hear?  During an annual physical by the occupational nurse working in a corporate clinic, a male employee tells the nurse that his high-stress job is causing trouble in his personal life. He further explains the he often gets so angry while driving to and from work that he has considered “getting even” with other drivers, how should the nurse respond? a. “anger is contagious and could result in major confrontation” b. “Try not to let your anger cause you to act impulsively” c. “expressing your anger to a stranger could result in an unsafe” d. It sound as if there are many situations that make you feel angry”  A client who has agoraphobia (a fear of crowds) is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care? a. Encourage substitution of positive thoughts for negative ones b. Establish trust by providing a calm, safe environment c. Progressively expose the client to larger crowds d. Encourage deep breathing when anxiety escalates in a crowd  A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone (Risperdal). When the client walks to the nurse’s station in a literally contracted position, he states that something has made his body confort into a monster. What action should the nurse take? 1. Medicate the client with the prescribed antipsychotic thioridazine (mellaril) 2. Offer the client a prescribed physical therapy hot pack for muscle spasms. 3. Direct client to occupational therapy to distract him from somatic complaints. 4. Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia.  A mental health worker (MHW) is caring for a client with escalating aggressive behavior. Which action by the MHW warrants immediate intervention by the nurse? 1. Is attempting to physically restrain the client. 2. Tells the client to go to the quiet area of the unit. 3. Is using a loud voice to talk to the client. 4. Remains at a distance of 4 feet from the client.  A client on the mental health unit is becoming more agitated, shouting at the staff, and pacing in the hallway. When a PRN medication is offered, the client refuses the medication and defiantly sits on the floor in the middle of the unit hallway. What nursing intervention should the nurse implement first? 1. Transport of the client to the seclusion room 2. Quietly approach the client with additional staff members. 3. C) Take other client in the area to the client lounge.  A client is admitted to the mental health unit and reports taking extra antianxiety medication because, “I’m so stressed out. I just wanted to go sleep” the nurse should plan one-on- one observation of the client based on which statement? 1. What should I do? Nothing seems to help.” 2. I have been so tired lately and needed to sleep.” 3. I really think that I don’t need to be here.” 4. I don’t want to talk. Nothing matters anymore.”  A male hospital employee is pushed out of the way by a female employee because of an oncoming gurney. The pushed employee becomes very angry and swings at the female employee. Both employees are referred for counseling with the staff psychiatric nurse. Which factor in the pushed employee’s history is most related to the reaction that occurred? 1. Is worried about losing his job to a woman 2. Tortured animals as a child. 3. Was physically abused by his mother 4. Hates to be touched by anyone  Client sitting in corner of day room during admission assessment, what nursing action B) Correct Answer: Ask client simple questions  How do you take Antabuse C) Correct Answer: Each morning beginning 48 hours after your last drink of alcohol Paul Wesley wishes you all the very best in your exam