Menatal Health/BH Hesi V2 QUESTIONS
AND ANSWERS
1. A 19 12 months antique female consumer with a prognosis of anorexia nervosa desires
to help serve dinner trays to different customers on a psychiatric unit.. What motion
should the nurse take
A. Encourage the purchaser self-motivation by way of asking her to pass trays for the
rest of the week. B. Provide an additional mission with the aid of asking the patron to
help feed the older clients.C. Suggest some other manner or this consumer to take part
within the unit's activities.D. Tell the purchaser that hospital hints permit best staff to skip
the trays. - ANS -advocate another manner for this customer to participate in unit
sports: anorexics advantage pride from providing others with meals and looking
them devour.. Such behaviors give a boost to their notion of self manipulate..
These customers ought to not be allowed to devise or put together food for unit
sports and their desires to achieve this should be redirected
2. a 22 year vintage male consumer is admitted to the emergency center following a
suicide strive.. His information display that that is his third suicide attempt within the past
years.. He's conscious, however does no longer respond to verbal commands for
remedy.. Which evaluation locating should spark off the nurse to put together the patron
for gastric lavage
- He ingested the drug 3 hours prior to admission to the emergency center.
- The family reviews that he took an entire bottle of acetaminophen (Tylenol).
- He is unresponsive to commands and is unable to cooperate with emetic therapy.
- Those with repeated suicide attempts preference punishment to alleviate their guilt. -
ANS -he is unresponsive to commands and is unable to cooperate with emetic
remedy: bc the purchaser is not able to observe instructions, emetic therapy
might be very hard to put into effect and gastric lavage could be essential
3. a 25 year vintage female customer has been mainly restless and the nurse reveals her
looking to depart the psychiatric unit.. She tells the nurse "please allow me go! I must
depart bc the name of the game police are after me".. Which response is satisfactory for
the nurse to make
- No one is when you, you're secure here.
- You'll experience better after you've got rested.
- I understand you must feel lonely and worried.
- Come with me on your room and I will sit with you. - ANS -include me in your room
and i will take a seat with you: this is the first-class reaction bc it gives guide
without judgement or demands
,4. a 27 12 months antique girl customer is admitted to the psychiatric health facility with a
prognosis of bipolar disease, manic segment.. She is worrying and energetic.. Which
intervention should the nurse consist of on this customers plan of care
A. Schedule her to attend various organization activities.B. Reinforce her potential to
make her own decisions.C. Encourage her to discover emotions of anger.D. Provide a
structural environment with little stimuli. - ANS -offer a structured environment with
little stimuli: clients within the manic phase of a bipolar ailment require decreased
stimuli and a established surroundings
5. a 30 year antique income manager tells the nurse "i'm thinking about a task alternate. I
don't feel like i am residing up to my capability." which of maslows developmental ranges
is the sales manager attempting to acquire
A. Self-Actualization
B. Loving and Belonging
C. Basic Needs
D. Safety and Security - ANS -self actualization: self actualization is the best level of
maslows developmental degrees, which is an try and fulfill ones complete
capacity.. Loving and belonging is identifying aid structures.. Fundamental wishes
is the first stage of maslows developmental degrees and is the muse upon which
better needs rest.. Folks that feel safe and relaxed in their environment perceive
themselves as having bodily safety and lack worry of harm
6. a 35 12 months antique male purchaser on the psychiatric ward of a fashionable medical
institution believes that someone is attempting to poison him.. The nurse understands
that a clients delusions are most likely associated with his
A. Early youth reports related to authority troubles. B. Anger approximately being
hospitalized.C. Low self-esteemD. Phobia worry of meals - ANS -low self-worth:
psychotic customers have trouble with accept as true with and have low self
esteem.. Nursing care need to be directed at building agree with and promoting
high-quality self confidence.. Sports with constrained attention and no opposition
have to be recommended in an effort to construct self esteem
7. a 35 12 months old male consumer who has been hospitalized for two weeks for
continual paranoia keeps to nation that someone is making an attempt to scouse borrow
his garb.. Which motion must the nurse enforce
- Encourage the customer to actively take part in assigned sports on the unit.
- Place a lock at the client's closet.
- Ignore the customer's paranoid ideation to extinguish these behaviors.
- Explain to the client that his suspicions are false. - ANS -encourage the consumer to
actively take part in assigned activities at the unit: diverting the clients interest
from paranoid ideation and inspiring him to complete assignments can be useful
in assisting him to broaden a fine self photo
,8. a 35 year antique married woman works full time in a manufacturing facility and has
been absent from paintings for 3 days at a time on several occasions.. Every time she
returns to paintings, she wears darkish glasses to cowl facial bruising.. Her supervisor
refers her to the occupational health nurse.. What assessment query is maximum
important for the nurse to to begin with use
A. Do you drink excessively?B. Did your husband beat you?C. How did this take place to
you? D. What did you do to deserve this? - ANS -how did this manifest to you: home
violence can found in numerous paperwork, which include sexual, bodily,
intellectual, and forget about.. The victim of spousal abuse is frequently scared of
can also experience at fault approximately the abuse, so a therapeutic relationship
ought to be hooked up with te purchaser the use of non judgmental, open ended
questions, so the patron is comfy o disclose details about the injury, if abuse is
suspected
9. a 38 year antique lady consumer is admitted with a prognosis of paranoid
schizophrenia.. Whilst her tray is introduced to her, she refuses to eat and tells the
nurse, "i recognise you are trying to poison me with that food".. Which reaction is most
appropriate for the nurse to make
A. I'll go away your tray here. I am to be had if you need anything elseB. You aren't being
poisoned. Why do you watched a person is attempting to poison you C. No one in this
unit has ever died from poisoning. You are secure right here.D. I will communicate in
your healthcare provider approximately the possibility of changing your diet - ANS -ill
depart your tray here.. I am available if you need some thing else: that is the
high-quality reaction.. The nurse does not argue with the patron nor demand that
she consume, however offers assist via agreeing to "be there if needed" (to warm
the meals)
10.a 40 12 months vintage male customer diagnosed with schizophrenia and alcohol
dependence has no longer had any site visitors or phone calls on the grounds that
admission.. He reports he has no circle of relatives that cares about him and changed
into living on the streets previous to this admission.. In keeping with ericksons theory of
psychosocial improvement, which stage is the client in at the moment
- Isolation.
- Stagnation.
- Despair.
- Role confusion. - ANS -stagnation: the consumer is in ericksons generativity vs.
Stagnation stage (ages 24-45), and meeting the task consists of keeping intimate
relationships and moving in the direction of growing a circle of relatives
11.a 45 yr old girl patron is admitted to the psychiatric unit for assessment.. Her husband
states that she has been reluctant to go away domestic for the closing six months.. The
purchaser has no longer gone to work for a month and has been terminated from her
job.. She has not left the residence when you consider that that point.. This customer is
displaying symptoms of what circumstance
, A. Claustrophobia B. AcrophobiaC. AgoraphobiaD. Post-annoying stress sickness - ANS
-agoraphobia: agoraphobia is the worry of crowds or being in an open place..
Consider a phobia is an unrealistic worry that's related to intense anxiety
12.a 45 12 months old male customer tells the nurse that he used to agree with that he
turned into jesus christ, but now he knows he isn't.. Which reaction is exceptional for the
nurse to make
A. Did you actually agree with you had been Jesus Christ?B. I think you are getting
wellC. Others have had similar thoughts when below stressD. Why did you think you
were Jesus Christ? - ANS -others have had comparable thoughts when under
strain: this reaction gives support by assuring the patron that others have
suffered as he has (additionally the principle on which AA acts)
a forty six year vintage girl patron has been on antipsychotic neuroleptics for the
beyond three days.. She has had a decrease in psychotic behavior and appears to
be responding properly to the medicine.. On the fourth day, the clients blood
strain will increase, she turns into light and febrile, and demonstrates muscular
rigidity.. Which motion ought to the nurse initiate
13.A. Place the purchaser on seizure precautions and monitor carefully. B. Immediately
transfer the purchaser to ICU.C. Describe the signs to the charge nurse and record on
the customers chart.D. No movement is needed right now as these are regarded aspect
effects of such drugs. - ANS -straight away switch the purchaser to the ICU: these
signs and symptoms are descriptive of neuroleptic malignant syndrome (NMS)
that's a very serious/lifestyles threatening reaction to the neuroleptic tablets.. The
primary signs of this syndrome are fever, stress, autonomic instability, and
encephalopathy.. Respiration failure, cardiovascular fall apart, arrhythmias, and/or
renal failure can bring about death.. This is an EMERGENCY state of affairs, and
the customer calls for immediately essential care
14.a 52 12 months antique male consumer in the ICU who has been oriented all of sudden
turns into disoriented and nervous.. Evaluation of VS and other physical parameters
screen no massive alternate and the nurse formulates the analysis "confusion
associated with ICU psychosis".. Which intervention is first-class to put in force
A. Move all machines far from the client's immediately area. B. Attempt to allay the
customers fears by way of explaining the etiology of his situation.C. Cluster care so that
short periods of rest can be scheduled all through the day.D. Extend visitation times for
own family and pals - ANS -cluster care so that brief durations of rest may be
scheduled throughout the day: the crucial care environment confronts clients with
an environment which provides stressors heightened through remedy modalities
that can show to be lifesaving.. Those stressors can bring about isolation and
confusion.. The great intervention is to offer the client with relaxation durations
15.a sixty five yr antique girl client complains to the nurse that currently she has been
hearing voices.. What query ought to the nurse ask this client first
AND ANSWERS
1. A 19 12 months antique female consumer with a prognosis of anorexia nervosa desires
to help serve dinner trays to different customers on a psychiatric unit.. What motion
should the nurse take
A. Encourage the purchaser self-motivation by way of asking her to pass trays for the
rest of the week. B. Provide an additional mission with the aid of asking the patron to
help feed the older clients.C. Suggest some other manner or this consumer to take part
within the unit's activities.D. Tell the purchaser that hospital hints permit best staff to skip
the trays. - ANS -advocate another manner for this customer to participate in unit
sports: anorexics advantage pride from providing others with meals and looking
them devour.. Such behaviors give a boost to their notion of self manipulate..
These customers ought to not be allowed to devise or put together food for unit
sports and their desires to achieve this should be redirected
2. a 22 year vintage male consumer is admitted to the emergency center following a
suicide strive.. His information display that that is his third suicide attempt within the past
years.. He's conscious, however does no longer respond to verbal commands for
remedy.. Which evaluation locating should spark off the nurse to put together the patron
for gastric lavage
- He ingested the drug 3 hours prior to admission to the emergency center.
- The family reviews that he took an entire bottle of acetaminophen (Tylenol).
- He is unresponsive to commands and is unable to cooperate with emetic therapy.
- Those with repeated suicide attempts preference punishment to alleviate their guilt. -
ANS -he is unresponsive to commands and is unable to cooperate with emetic
remedy: bc the purchaser is not able to observe instructions, emetic therapy
might be very hard to put into effect and gastric lavage could be essential
3. a 25 year vintage female customer has been mainly restless and the nurse reveals her
looking to depart the psychiatric unit.. She tells the nurse "please allow me go! I must
depart bc the name of the game police are after me".. Which response is satisfactory for
the nurse to make
- No one is when you, you're secure here.
- You'll experience better after you've got rested.
- I understand you must feel lonely and worried.
- Come with me on your room and I will sit with you. - ANS -include me in your room
and i will take a seat with you: this is the first-class reaction bc it gives guide
without judgement or demands
,4. a 27 12 months antique girl customer is admitted to the psychiatric health facility with a
prognosis of bipolar disease, manic segment.. She is worrying and energetic.. Which
intervention should the nurse consist of on this customers plan of care
A. Schedule her to attend various organization activities.B. Reinforce her potential to
make her own decisions.C. Encourage her to discover emotions of anger.D. Provide a
structural environment with little stimuli. - ANS -offer a structured environment with
little stimuli: clients within the manic phase of a bipolar ailment require decreased
stimuli and a established surroundings
5. a 30 year antique income manager tells the nurse "i'm thinking about a task alternate. I
don't feel like i am residing up to my capability." which of maslows developmental ranges
is the sales manager attempting to acquire
A. Self-Actualization
B. Loving and Belonging
C. Basic Needs
D. Safety and Security - ANS -self actualization: self actualization is the best level of
maslows developmental degrees, which is an try and fulfill ones complete
capacity.. Loving and belonging is identifying aid structures.. Fundamental wishes
is the first stage of maslows developmental degrees and is the muse upon which
better needs rest.. Folks that feel safe and relaxed in their environment perceive
themselves as having bodily safety and lack worry of harm
6. a 35 12 months antique male purchaser on the psychiatric ward of a fashionable medical
institution believes that someone is attempting to poison him.. The nurse understands
that a clients delusions are most likely associated with his
A. Early youth reports related to authority troubles. B. Anger approximately being
hospitalized.C. Low self-esteemD. Phobia worry of meals - ANS -low self-worth:
psychotic customers have trouble with accept as true with and have low self
esteem.. Nursing care need to be directed at building agree with and promoting
high-quality self confidence.. Sports with constrained attention and no opposition
have to be recommended in an effort to construct self esteem
7. a 35 12 months old male consumer who has been hospitalized for two weeks for
continual paranoia keeps to nation that someone is making an attempt to scouse borrow
his garb.. Which motion must the nurse enforce
- Encourage the customer to actively take part in assigned sports on the unit.
- Place a lock at the client's closet.
- Ignore the customer's paranoid ideation to extinguish these behaviors.
- Explain to the client that his suspicions are false. - ANS -encourage the consumer to
actively take part in assigned activities at the unit: diverting the clients interest
from paranoid ideation and inspiring him to complete assignments can be useful
in assisting him to broaden a fine self photo
,8. a 35 year antique married woman works full time in a manufacturing facility and has
been absent from paintings for 3 days at a time on several occasions.. Every time she
returns to paintings, she wears darkish glasses to cowl facial bruising.. Her supervisor
refers her to the occupational health nurse.. What assessment query is maximum
important for the nurse to to begin with use
A. Do you drink excessively?B. Did your husband beat you?C. How did this take place to
you? D. What did you do to deserve this? - ANS -how did this manifest to you: home
violence can found in numerous paperwork, which include sexual, bodily,
intellectual, and forget about.. The victim of spousal abuse is frequently scared of
can also experience at fault approximately the abuse, so a therapeutic relationship
ought to be hooked up with te purchaser the use of non judgmental, open ended
questions, so the patron is comfy o disclose details about the injury, if abuse is
suspected
9. a 38 year antique lady consumer is admitted with a prognosis of paranoid
schizophrenia.. Whilst her tray is introduced to her, she refuses to eat and tells the
nurse, "i recognise you are trying to poison me with that food".. Which reaction is most
appropriate for the nurse to make
A. I'll go away your tray here. I am to be had if you need anything elseB. You aren't being
poisoned. Why do you watched a person is attempting to poison you C. No one in this
unit has ever died from poisoning. You are secure right here.D. I will communicate in
your healthcare provider approximately the possibility of changing your diet - ANS -ill
depart your tray here.. I am available if you need some thing else: that is the
high-quality reaction.. The nurse does not argue with the patron nor demand that
she consume, however offers assist via agreeing to "be there if needed" (to warm
the meals)
10.a 40 12 months vintage male customer diagnosed with schizophrenia and alcohol
dependence has no longer had any site visitors or phone calls on the grounds that
admission.. He reports he has no circle of relatives that cares about him and changed
into living on the streets previous to this admission.. In keeping with ericksons theory of
psychosocial improvement, which stage is the client in at the moment
- Isolation.
- Stagnation.
- Despair.
- Role confusion. - ANS -stagnation: the consumer is in ericksons generativity vs.
Stagnation stage (ages 24-45), and meeting the task consists of keeping intimate
relationships and moving in the direction of growing a circle of relatives
11.a 45 yr old girl patron is admitted to the psychiatric unit for assessment.. Her husband
states that she has been reluctant to go away domestic for the closing six months.. The
purchaser has no longer gone to work for a month and has been terminated from her
job.. She has not left the residence when you consider that that point.. This customer is
displaying symptoms of what circumstance
, A. Claustrophobia B. AcrophobiaC. AgoraphobiaD. Post-annoying stress sickness - ANS
-agoraphobia: agoraphobia is the worry of crowds or being in an open place..
Consider a phobia is an unrealistic worry that's related to intense anxiety
12.a 45 12 months old male customer tells the nurse that he used to agree with that he
turned into jesus christ, but now he knows he isn't.. Which reaction is exceptional for the
nurse to make
A. Did you actually agree with you had been Jesus Christ?B. I think you are getting
wellC. Others have had similar thoughts when below stressD. Why did you think you
were Jesus Christ? - ANS -others have had comparable thoughts when under
strain: this reaction gives support by assuring the patron that others have
suffered as he has (additionally the principle on which AA acts)
a forty six year vintage girl patron has been on antipsychotic neuroleptics for the
beyond three days.. She has had a decrease in psychotic behavior and appears to
be responding properly to the medicine.. On the fourth day, the clients blood
strain will increase, she turns into light and febrile, and demonstrates muscular
rigidity.. Which motion ought to the nurse initiate
13.A. Place the purchaser on seizure precautions and monitor carefully. B. Immediately
transfer the purchaser to ICU.C. Describe the signs to the charge nurse and record on
the customers chart.D. No movement is needed right now as these are regarded aspect
effects of such drugs. - ANS -straight away switch the purchaser to the ICU: these
signs and symptoms are descriptive of neuroleptic malignant syndrome (NMS)
that's a very serious/lifestyles threatening reaction to the neuroleptic tablets.. The
primary signs of this syndrome are fever, stress, autonomic instability, and
encephalopathy.. Respiration failure, cardiovascular fall apart, arrhythmias, and/or
renal failure can bring about death.. This is an EMERGENCY state of affairs, and
the customer calls for immediately essential care
14.a 52 12 months antique male consumer in the ICU who has been oriented all of sudden
turns into disoriented and nervous.. Evaluation of VS and other physical parameters
screen no massive alternate and the nurse formulates the analysis "confusion
associated with ICU psychosis".. Which intervention is first-class to put in force
A. Move all machines far from the client's immediately area. B. Attempt to allay the
customers fears by way of explaining the etiology of his situation.C. Cluster care so that
short periods of rest can be scheduled all through the day.D. Extend visitation times for
own family and pals - ANS -cluster care so that brief durations of rest may be
scheduled throughout the day: the crucial care environment confronts clients with
an environment which provides stressors heightened through remedy modalities
that can show to be lifesaving.. Those stressors can bring about isolation and
confusion.. The great intervention is to offer the client with relaxation durations
15.a sixty five yr antique girl client complains to the nurse that currently she has been
hearing voices.. What query ought to the nurse ask this client first
