MENTAL HESI /2025/2026
EXAMINATION
The emergency department nurse is providing care for a rape victim.
Which action represents an essential element of care for this client?
Providing nonjudgmental care.
Conveying outrage that this occurred.
Sympathizing with the client's sense of shame.
Encouraging the client to divulge all the details - ANSWER-Providing
nonjudgmental care.
The nurse is reviewing labs for a client who is taking clozapine, 25mg
QD for treatment of disorganized schizophrenia. The labs are
documented as follows: RBC 4.5 million/mcL, WBC 1000/mcL, TSH
1.2 mc-IU. Based on these results, which order should the nurse
anticipate the health care provider to write?
,Discontinue clozapine.
Administer levothyroxine sodium 25 mcg QD.
Administer ferrous sulfate 100mg QD.
Decrease clozapine to 12.5 mg QD, start levothyroxine sodium 50 mcg
QD. - ANSWER-Discontinue clozapine.
Rationale
Agranulocytosis is an adverse side effect of clozapine that can cause
lethal infections. Based on the client's results, clozapine should be
discontinued; the thyroid and RBC results are normal and do not need to
be treated.
A client with stage 2 Alzheimer's disease is being cared for at home by
the spouse. The client's spouse tells the nurse about the emotional
difficulties involved in providing fulltime care at home. Which self-care
activity is most important for the nurse to recommend to the spouse?
Periodic times of respite from caregiving.
,Regular attendance at church services.
Participation in reminiscence therapy.
Establishment of a predictable daily schedule. - ANSWER-Periodic
times of respite from caregiving.
Rationale
Caregiver role strain may be attributed to many different factors. The
nurse must become familiar with this diagnosis in order to accurately
assess the caregiver and offer effective interventions. One important
recommendation is to have the caregiver incorporate periodic breaks as
part of the daily routine to relieve stress. The nurse should contact the
client's manager and provide the client's caregiver a list of agencies
offering "Respite Care".
A client with delirium keeps attempting to get out of bed and has fallen
twice, despite being under close-observation. The charge nurse calls the
health care provider to obtain an order for mechanical restraints. Which
statement is correct regarding the mechanical restraint policy?
The client will need to remain on close-observation with a
documentation note every 15 minutes.
, The client no longer require close-observation, but must be checked at
regular intervals.
The client may be sedated and left alone as long as the restraints remain
in place.
Restraints may be applied based on verbal orders received over the
phone. - ANSWER-The client will need to remain on close-observation
with a documentation note every 15 minutes.
Rationale
Restraints are the last option to use to ensure client safety. A written
order is required by a health care provider and the client require
continued close-observation, even if mechanical restrained.
A client with long-term alcohol addiction is admitted to the emergency
department. Which medications should the nurse anticipate the
healthcare provider will prescribe for this client?
Diazepam.
Methadone.
EXAMINATION
The emergency department nurse is providing care for a rape victim.
Which action represents an essential element of care for this client?
Providing nonjudgmental care.
Conveying outrage that this occurred.
Sympathizing with the client's sense of shame.
Encouraging the client to divulge all the details - ANSWER-Providing
nonjudgmental care.
The nurse is reviewing labs for a client who is taking clozapine, 25mg
QD for treatment of disorganized schizophrenia. The labs are
documented as follows: RBC 4.5 million/mcL, WBC 1000/mcL, TSH
1.2 mc-IU. Based on these results, which order should the nurse
anticipate the health care provider to write?
,Discontinue clozapine.
Administer levothyroxine sodium 25 mcg QD.
Administer ferrous sulfate 100mg QD.
Decrease clozapine to 12.5 mg QD, start levothyroxine sodium 50 mcg
QD. - ANSWER-Discontinue clozapine.
Rationale
Agranulocytosis is an adverse side effect of clozapine that can cause
lethal infections. Based on the client's results, clozapine should be
discontinued; the thyroid and RBC results are normal and do not need to
be treated.
A client with stage 2 Alzheimer's disease is being cared for at home by
the spouse. The client's spouse tells the nurse about the emotional
difficulties involved in providing fulltime care at home. Which self-care
activity is most important for the nurse to recommend to the spouse?
Periodic times of respite from caregiving.
,Regular attendance at church services.
Participation in reminiscence therapy.
Establishment of a predictable daily schedule. - ANSWER-Periodic
times of respite from caregiving.
Rationale
Caregiver role strain may be attributed to many different factors. The
nurse must become familiar with this diagnosis in order to accurately
assess the caregiver and offer effective interventions. One important
recommendation is to have the caregiver incorporate periodic breaks as
part of the daily routine to relieve stress. The nurse should contact the
client's manager and provide the client's caregiver a list of agencies
offering "Respite Care".
A client with delirium keeps attempting to get out of bed and has fallen
twice, despite being under close-observation. The charge nurse calls the
health care provider to obtain an order for mechanical restraints. Which
statement is correct regarding the mechanical restraint policy?
The client will need to remain on close-observation with a
documentation note every 15 minutes.
, The client no longer require close-observation, but must be checked at
regular intervals.
The client may be sedated and left alone as long as the restraints remain
in place.
Restraints may be applied based on verbal orders received over the
phone. - ANSWER-The client will need to remain on close-observation
with a documentation note every 15 minutes.
Rationale
Restraints are the last option to use to ensure client safety. A written
order is required by a health care provider and the client require
continued close-observation, even if mechanical restrained.
A client with long-term alcohol addiction is admitted to the emergency
department. Which medications should the nurse anticipate the
healthcare provider will prescribe for this client?
Diazepam.
Methadone.
