HESI Mental Health exam

HESI Mental Health exam 1. While caring for an older client, the nurse observes multiple bruises over the client’s legs, arms, back, and gluteal areas. When the client contact, the nurse suspects elder abuse. What action should the nurse indicate? Measure and document size, shape and color of the bruised areas. 2. A client who is homeless is diagnosed with schizophrenia and admitted on an involuntary basis to e mental health hospital 4 days ago. The client stopped taking prescribed antipsychotic drugs approximately one month ago. Since hospitalization the client continues to have poor judgment and refuses all medications. What action should the nurse take? Administer a long acting antipsychotic medication so that the client can be discharged to a shelter. ? 3. After receiving treatment for anorexia, a student asks the school nurse for permission to work in the school cafeteria as part of the school’s wok study program. What action should the nurse take? Recommend assignment to the receptionist’s office. 4. A male client comes to the emergency center because he has an erection that will not resolve. The client reports that he is taking trazodone (desyrel) for insomnia. Which information is most important for the nurse to ask this client? Have you taken any medication for erectile dysfunction? 5. On admission to the mental health unit, a client diagnosed with schizophrenia tells the nurse that he is the son of God. Based on this statement, which intervention should the nurse include in this client’s plan of care? Confront his delusion as not consistent with reality. 6. The nurse on the day shift receives report about a client with depression who was in bed most of the weekend. The nurse walks into the client’s room in the morning and finds the client in bed. What intervention I best for the nurse to implement? Assist the client to get out of bed and involved in an activity. 7. Which client information indicates the need for the nurse to use the CAGE questionnaire during the admission interview? Describes self as a social drinker who drinks alcoholic beverages daily. 8. A female client admitted to the mental health unit stats to shout and scream at the nurse. What is he best approach for the nurse to take? Stay quietly with the client. 9. A woman is brought to the psychiatric clinic by her husband. He reports that his wife is reluctant to leave home because of what she describes as a fear of open places and crows. Which nursing problems applies to the client’s behavior? Anxiety related to real or perceived threat to physical integrity. 10. A client is receiving benztropine mesylate (Cogentin) for drug-induced extrapyramidal syndrome (EPS). Which finding indicates that the RN should further evaluate the client? Presence of a dry mouth. 11. A male client in the mental health unit is guarded and vaguely answers the nurse’s questions. He isolates in his room and sometimes opens the door to peek into the hall. Which problem can the RN anticipate? Delusions of persecution. A client with depression remains in bed most of the day, and declines activities. 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 client discontinued antipsychotic medication for several days. Which medication should also be discontinued? a. Lithium. (Lithotabs) b. Benzotropine (Cogentin). c. Alprazolam (Xanax). d. Magnesium (Milk of Magnesia). A female client requests that her husband be allowed to stay in the room during the admission assessment. When interviewing the client, the RN notes a discrepancy between the client’s verbal and nonverbal communication. What action does the RN 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 HCP. B. Encourage the client to suck on hard candy to relieve the symptoms. C. No action 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 the 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 for 12 hours prior to the first dose. C. Attend monthly meetings of alcoholics anonymous. D. Admit to others that he is a substance user. 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 is high-stress job is causing trouble in his personal life. He further explains that 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 situation.” D. “It sounds 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 RN is reinforcing the process. Which intervention has the highest priority for this client’s plan of care? A. Encourage substitution of positive thoughts and 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.