NUR 2520C - 2020 HESI Mental Health (Questions and Answers)

2020 HESI Mental Health 1. A male client with bipolar disorder who began taking lithium carbonate five days ago is complaining of excessive thirst, and the RN finds him attempting to drink water from the bathroom sink faucet. Which intervention should the RN implement? 2. A mental health worker is caring for a client with escalating aggressive behavior. Which action by the MHW warrant immediate intervention by the RN? 3. A client is admitted to the mental health unit and reports taking extra antianxiety medication because, “I’m so stressed out. I just want to go to sleep.” The RN should plan one-on-one observation of the client based on which statement? 4. The RN is performing intake interviews at a psychiatric clinic. A female client with a known history of drug abuse reports that she had a heart attack four years ago. Use of which substance places the client at highest risk for myocardial infarction? 5. 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 ask the client? 6. The RN on the day shift receive report about a client with depression who was in bed most of the weekend. The RN walks into the client’s room in the morning and finds the client in bed. What intervention is best for the RN to implement? 7. A female client admitted to the mental health unit starts to shout and scream at the RN. What is the best approach for the RN to take? 8. A young adult female visits the mental health clinic complaining of diarrhea, headache, and muscle aches. She is afebrile, denies chills, and all laboratory findings are within normal limits. During the physical assessment, the client tells the RN that her sister thinks she is neurotic and calls her a hypochondriac. Which response is best for the RN to provide? 9. A mental health worker is caring for a client with escalating aggressive behavior. Which action by the mental health worker warrants immediate intervention by the RN? 10. When developing a plan of care for a client admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing problem has the highest priority? 11. A female client on a psychiatric unit is sweating profusely while she vigorously does push-ups and then runs the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbance, the client shouts, “I am the boss here. I do what I want.” Which nursing problem best supports these observations? 12. A RN is preparing the physical environment to interview a new client for admission to the mental health unit. Which environmental setting facilitates the best outcome of the interview? 13. The RN is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? (SOA) 14. The RN is admitting a male client who takes lithium carbonate (Eskalith) twice a day. Which information should the RN report to the HCP immediately? 15. A homeless client who reports feeling sad and depressed tells the mental health nurse that in the past 2 days she has only had 4 hours of sleep. Which action is most important for the RN to implement within the first 24 hours after treatment is initiated? 16. A RN is teaching a client about initiation of a prescribed abstinence therapy using Disulfiram (Antabuse). What information should the client acknowledge understanding? 17. Which client statement suggests the RN that the client is using a defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit? 18. The RN documents the mental status of a female client who has been hospitalized for several days by court order. The client states”I don’t need to be here,” and tells the RN that she believes that the t.v talks to her. The RN should document these assessment statements in which section of the mental status exam? 19. An older ale client with schizophrenia is found smearing feces n the bathroom walls of the chronic mental health unit where he resides. What action should the RN implement? 20. A male client tells the RN that he does not want to take the atypical antipsychotic drug, olanzapine (Zypexa), because of the side effects he experienced when he took the drug for a year. Which experience is most likely related to taking olanzapine? 21. Following involvement in a MVC, a middle aged adult client is admitted to the hospital with multiple facial fractures. The client’s blood alcohol level is high on admission. Which PRN prescription should be administered if the client begins to exhibit signs and symptoms of delirium tremens (DTs)? 22. A female client on a psychiatric unit is sweating profusely while she vigorously does push-ups and then runs the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbance, the client shouts, "I am the boss here. I do what I want." Which nursing problem best supports these observations? 23. The RN 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? 24. The RN on the day shift receive report about a client with depression who was in bed most of the weekend. The RN walks into the client's room in the morning and finds the client in bed. What intervention is best for the RN to implement? 25. A patient who has been on an antidepressant for 2 weeks. What should you watch for? 26. patient states "I can't get my thoughts together I should really sell my car. It’s not in here. Let's buy a car. What is the patient experiencing? : 27. A patient won't take oral meds that is going through alcohol withdrawal. The nurse starts giving saline lock per alcohol protocol and thiamine. What do you tell them that it will help with recovery? 28. A nurse visits a community half way house with one bathroom. The nurse notices urine all over the walls of the bathroom. The toilet is clogged with feces and paper towels. 29. Older man who recently got divorced and is 2 years sober, and an alcoholic loves God. He loves kids also. What should nurse ask at his initial interaction? 30. Schizoprenia return to clinic 2 weeks after recieving dose of haldol; important info for the nurse to obtain during this visit – 31. male who was found sitting in the middle of a busy street is brought to the emergency department. Confused and has difficulty answering questions. After ruling out a physiological etiology for the client’s behavior. When admitting the client to the unit, which action is most important for the nurse to take? 32. An adolescent male client is hospitalized after he threatened a teacher at school. He admits feeling angry because his mother tricked him and brought him to the hospital. The client states that when his mother visits, he plans to get his belongings from her, but he is not going to talk to her. Which activity is most important for the nurse to complete before the mother arrives? 33. Chronically depressed older male client of a long term care facility becomes more reclusive and today refuses to leave room: 34. . During admission to the psychiatric unit, a female client is extremely anxious and states that she is worried about the sun coming up the next day. What intervention is most important for the RN to implement during the admission process? 35. .The nurse is assessing a client with postpartum depression for changes in the …….Sign & Symptoms that are consistent with post partum depression? Select all that apply 36. A client with borderline personality disorder tells the nurse, “You are the best nurse on the unit! The other nurses don’t care about me the way you do.” Which response is best for the nurse to provide this client? 37. A sales executive presents to the psychiatric office for an initial evaluation, and tells the nurse “My therapist said my wife was having an affair. I had drinking problem for years, but I have been sober for 3 years. I believe in God……. What response is best for the nurse to provide? 38. The nurse is taking the history of a young adult female who is 5 feet 4 inches tall and weighs. What is the most important for the nurse to address immediately? 39. A young woman is preparing to be discharged from the psychiatric unit. Which nursing intervention is most important for the nurse to include in this phase of the nurse client relationship: 40. a client is being discharged with a prescription of paroxetine. which instruction is most important for the nurse to include in this client’s discharge? 41. client sitting in corner of day room during admission assessment, what nursing action – ask 42. An older man with a hx of falls at home tells the clinic nurse that his son, who was incarcerated last year for assault and battery, has become abusive since his release from prison. Which intervention is most important for the nurse to implement? 43. The nurse is caring for a client who had a myocardial infarction and is experiencing death anxiety. Which action should the nurse implement? 44. A client with schizophrenia explains that she has 20 children and then very seriously points to the RN and explains that she is one of them. What is the most therapeutic response for the RN to provide/ 45. male client admitted depression and self mutilation – 46. male employee says i'm gonna shoot a coworker - find out if he has a weapon Assessing male client with paranoia, which behavior can this client be expected to exhibit – A young female client is admitted to the emergency room because she was raped that evening by her date. How should the nurse record the client’s chief complaint in the medical record? A client is discussing feelings related to a recent loss with the nurse. The nurse remains silent A female client with obsessive compulsive disorder complains that she is feels “driven” to check the locks on her front door at…Which response is best for the nurse to provide? The nurse on the day shift receives report about a client with depression who was in bed most of the weekend. The nurse the morning and finds the client in bed. What intervention is best for the nurse to implement? A client is admitted to the mental health unit and reports taking extra antianxiety medication because, “I’m so stressed out. I just…” The nurse should plan one-on-one observation of the client based on which statement? What is the most important goal for a client with major depression who has been receiving an antidepressant medication for two weeks? A mental health worker is caring for a client with escalating aggressive behavior. Which action by the mental health worker...intervention by the nurse? An older male client with schizophrenia is found smearing feces on the bathroom walls of the chronic mental health unit where he resides. What should the nurse implement? A young adult female visits the mental health clinic complaining of diarrhea, headache, and muscle aches. She is...laboratory findings are within normal limits. During the physical assessment, the client tells the nurse that her sister...hypochondriac. Which response is best for the nurse to provide? After meeting with a healthcare provider, a client who is diagnosed with bipolar disorder is screaming and stomping. Which action should the nurse take? A client with depression is not attentive to personal hygiene, uses television watching as a means of escape from...inability to enjoy the things that once gave them pleasure. Which coping strategy should the nurse include in the plan of care? A male college student visits the student health center for his annual physical examination. His vital signs and blood glucose...range. His height is 6 feet and 1 inch (185.4 cm), and he weighs 135 pounds (61.36kg). What additional information is most...obtain? A young male who was recently diagnosed with bipolar disorder takes lithium carbonate daily. He is graduating...he tells the school nurse that wants to live away from home for college. What information is most important for...family? A client who is admitted to the substance abuse center reports having nightmares – A client admitted to the psychiatric unit for alcohol dependency- . During the initial nursing interview. “sometimes my thoughts go so fast” –