RN HESI CASE STUDY – PSYCHOSIS
QUESTIONS AND ANSWERS
1. Which thought process describes the client’s inability to leave his apartment because he
thinks someone is waiting to kill him?
A. Hallucination
B. Phobia
C. Delusions
D. Confabulation
Answer: C. Delusions √√
2. When the client explains that someone has been following him and is waiting outside the
door of the ED, how should the nurse respond?
A. "Believe me. No one has followed you here."
B. "You must be concerned, but you are safe here."
C. "The police will make sure no one is out there."
D. "Why do you think that someone is out there?"
Answer: B. "You must be concerned, but you are safe here." √√
3. The nurse observes the client looking to the corner of the room and mumbling to himself.
Which term fits this observation?
A. Delusions
B. Depersonalization
C. Hallucinations
D. Disorientation
Answer: C. Hallucinations √√
4. The client admits that the voices he hears have been getting louder over the past couple
of weeks. Which question should the nurse ask next?
, A. "What helps the voices go away?"
B. "How long have you heard voices?"
C. "When do the voices get louder?"
D. "What do the voices say?"
Answer: D. "What do the voices say?" √√
5. Which medication(s) should the nurse anticipate giving the client after securing a
prescription from the healthcare provider? (Select all that apply)
A. Short-acting anxiolytic (benzodiazepines)
B. Antipsychotic medication
C. Mood-stabilizing medication
D. Nonbenzodiazepine anxiolytic
E. Antidepressant
Answer: A. Short-acting anxiolytic (benzodiazepines), B. Antipsychotic medication √√
6. The nurse understands that the purpose of the urine drug screen is to assess the client for
what important information?
A. Detection of substances that may have caused the client’s delusions and/or
hallucinations
B. Determination of the approximate time the client stopped taking his medications
C. Provision of information about the type of psychosis the client is experiencing
D. Documentation of medication noncompliance
Answer: A. Detection of substances that may have caused the client’s delusions and/or
hallucinations √√
7. Which lab value(s) from the urinalysis can the nurse expect to be related to the client’s
10-pound weight loss in the past 2 weeks? (Select all that apply)
A. Positive for red blood cells
B. Positive ketones
C. Decreased urine pH
QUESTIONS AND ANSWERS
1. Which thought process describes the client’s inability to leave his apartment because he
thinks someone is waiting to kill him?
A. Hallucination
B. Phobia
C. Delusions
D. Confabulation
Answer: C. Delusions √√
2. When the client explains that someone has been following him and is waiting outside the
door of the ED, how should the nurse respond?
A. "Believe me. No one has followed you here."
B. "You must be concerned, but you are safe here."
C. "The police will make sure no one is out there."
D. "Why do you think that someone is out there?"
Answer: B. "You must be concerned, but you are safe here." √√
3. The nurse observes the client looking to the corner of the room and mumbling to himself.
Which term fits this observation?
A. Delusions
B. Depersonalization
C. Hallucinations
D. Disorientation
Answer: C. Hallucinations √√
4. The client admits that the voices he hears have been getting louder over the past couple
of weeks. Which question should the nurse ask next?
, A. "What helps the voices go away?"
B. "How long have you heard voices?"
C. "When do the voices get louder?"
D. "What do the voices say?"
Answer: D. "What do the voices say?" √√
5. Which medication(s) should the nurse anticipate giving the client after securing a
prescription from the healthcare provider? (Select all that apply)
A. Short-acting anxiolytic (benzodiazepines)
B. Antipsychotic medication
C. Mood-stabilizing medication
D. Nonbenzodiazepine anxiolytic
E. Antidepressant
Answer: A. Short-acting anxiolytic (benzodiazepines), B. Antipsychotic medication √√
6. The nurse understands that the purpose of the urine drug screen is to assess the client for
what important information?
A. Detection of substances that may have caused the client’s delusions and/or
hallucinations
B. Determination of the approximate time the client stopped taking his medications
C. Provision of information about the type of psychosis the client is experiencing
D. Documentation of medication noncompliance
Answer: A. Detection of substances that may have caused the client’s delusions and/or
hallucinations √√
7. Which lab value(s) from the urinalysis can the nurse expect to be related to the client’s
10-pound weight loss in the past 2 weeks? (Select all that apply)
A. Positive for red blood cells
B. Positive ketones
C. Decreased urine pH
