MENTAL HEALTH HESI EXAM VERSION 4 NEWEST ACTUAL EXAM COMPLETE QUESTIONS AND CORRECT DETAILED ANSWERS (VERIFIED ANSWERS) WITH RATIONALES

The nurse completes a physical assessment. When asked what brought her to the hospital, the client replies that things just aren't right and begins to cry. After further conversation, the client describes her mood as very sad now. She rarely goes out or invites friends to visit. She admits that she feels like strangers are saying bad things about her. Sometimes she hears a man's voice that is a little bit scary. What is the priority focused nursing assessment? - ANSWER Determine how long the client has been hearing the voice and what it is saying. Rationale: Determining if voices are being heard and the type of voices are priority. The nurse must assess the content of the auditory hallucinations for the presence of command hallucinations. Command hallucinations may be telling the client to harm herself or others. The client is assessed by the nurse, a social worker, and the healthcare provider (HCP). Based on their assessments, hospitalization is recommended for psychotic depression. Which behavior is inconsistent with depression? - ANSWER Hearing a man's voice. Rationale: Auditory hallucinations are inconsistent with depression and are more likely to occur with psychoses. However, clients may experience a psychotic depression in which there is evidence of psychosis. The nurse asks the client to sign the consent for treatment. If the client refuses treatment, which behaviors justify short-term involuntary treatment? (Select all that apply. One, some, or all options may be correct.) - ANSWER Unable to meet basic self-care needs. Rationale: Involuntary treatment can be initiated if the client is unable to meet basic self-care needs in such a way that he or she is a danger to self. States she has a plan to harm herself. Rationale: Short-term involuntary care may be initiated to protect the client if she has a plan to harm herself. It can also be initiated if she presents an intentional danger to others