RN CARE HOPE MENTAL HEALTH HESI
Total Questions : 49
Showing 25 questions, Sign in for moreThe nurse is initiating an interview with a client in the emergency department who presents with a fractured ulna and swollen, red lips and nose. The client's spouse is pacing outside the door of the examination room. Which action should the nurse take?
Explanation
A. While obtaining the client's history is important, ensuring privacy is a priority to maintain confidentiality and facilitate open communication.
B. Inviting a colleague to document is not the immediate priority; privacy is crucial in the initial stages of the interview.
C. Closing the examination room door for privacy is the most appropriate action to create a confidential and secure environment for the client to discuss their injuries and provide a history.
D. Requesting hospital security is not necessary at this point, as the spouse pacing outside does not necessarily indicate a security threat.
An adolescent who is exhibiting a depressed affect receives a prescription for an antidepressant drug. While the client is taking the antidepressant, which comparison of the client’s behavior before and after taking the drug is most important for the nurse to obtain?
Explanation
A. Level of activity, interactions with others, and appetite are important aspects, but the emotional quality of attitude is central in assessing the effectiveness of an antidepressant.
Changes in mood and affect are critical indicators of the drug's impact on the client's mental health.
B. Interactions with others provide valuable information but may not capture the internal emotional experience of the client.
C. The emotional quality of attitude reflects the client's internal state and is a key indicator of the antidepressant's impact on their depressive symptoms.
D. Appetite is a relevant aspect, but it may not be as direct an indicator of the antidepressant's efficacy as changes in the emotional quality of attitude.
The nurse is leading a group on the inpatient psychiatric unit. Which approach should the nurse use during the working phase of group development?
Explanation
A. Helping clients identify areas of problem in their lives is more characteristic of the orientation phase of group development, where the group establishes trust and defines the purpose and goals.
B. Discussing ways to use new coping skills learned is appropriate during the working phase.
This phase focuses on problem-solving, decision-making, and achieving the goals identified in the orientation phase.
C. Establishing a rapport with group members is crucial during the orientation phase to build trust and create a safe environment for group members to share their experiences.
D. Clarifying the nurse’s role and clients’ responsibilities is more relevant in the orientation phase as the group establishes structure and guidelines.
An adult client presents to the community mental health center accompanied by the client’s spouse who reports that the client has been acting impulsively. The client has spent a large amount of money lately, made several last-minute decisions to take trips, sleeps only 2 to 4 hours a night, and has lost 33 pounds (15 kg) in the last 2 months. Which nursing problem has the greatest nursing priority?
Explanation
A. While sleep deprivation is a concern, the client's impulsive behavior poses a greater immediate risk, making "Risk for self-directed violence related to impulsive behavior" the priority.
B. Ineffective coping may be a contributing factor, but the risk of self-directed violence takes precedence as the primary concern.
C. The client's impulsive behavior increases the risk of self-directed violence, making it the most urgent nursing priority.
D. Imbalanced nutrition is a concern, but the immediate risk of self-directed violence requires more immediate attention.
A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?
Explanation
A. The client's statements about having an IQ of 400+, being married to a movie star, and suspecting his brother's intentions may indicate a distorted perception of reality, suggesting disturbed sensory perception. This priority addresses the potential psychosis and immediate safety concerns.
B. Compromised family coping, while important, is a secondary consideration. Addressing the client's altered sensory perception takes precedence to ensure their safety and
stabilization.
C. Ineffective sexual patterns are not as immediate concerns as the potential distorted sensory perception. Ensuring the client's mental stability is the primary goal upon admission to the psychiatric unit.
D. Impaired environmental interpretation is not as immediate concerns as the potential distorted sensory perception. Ensuring the client's mental stability is the primary goal upon admission to the psychiatric unit.
A young adult male client is admitted to the psychiatric unit because of a recent suicide attempt. His wife filed for divorce six months ago, he lost his job three months ago, and his best friend moved to another city two weeks ago. Which intervention should the nurse include in this client’s plan of care?
Explanation
A. Avoiding discussing subjects that upset the client may hinder therapeutic communication and exploration of feelings, making it less effective for the client's recovery.
B. Encouraging activities that allow the client to exert control over his environment helps empower the client and regain a sense of agency, which is important for improving mental health.
C. Allowing the client time alone may be appropriate at times, but encouraging activities that promote control is a more proactive and empowering intervention.
D. Encouraging interaction with persons recovering from depression may be beneficial, but the client's need for control over his environment takes precedence in this scenario.
The nurse completes an assessment of a client experiencing intimate partner violence (IPV). Which finding of the injuries should the nurse include in the documentation?
Explanation
A. Documenting the client’s feelings is important but may not provide objective evidence of injuries.
B. The significant other’s statement may be biased and may not accurately represent the client's injuries.
C. A general description may lack specificity, making it difficult to convey the extent and nature of the injuries.
D. Photographs are objective and provide visual documentation of the injuries, offering a clear and accurate record for legal and healthcare purposes.
When assessing a client who takes psychotropic medications, the nurse notes that the client has uncontrollable hand movements and is excessively protruding the tongue. Which assessment in the client’s record should the nurse review?
Explanation
A. The healthcare provider's history and physical may provide information about the client's overall health but may not specifically address the observed symptoms.
B. Recent urine drug testing (UDT) results may reveal drug use but may not be directly related to the observed involuntary movements.
C. The baseline nursing admission assessment may provide general information but may not specifically address medication side effects.
D. The Abnormal Involuntary Movement Scale (AIMS) is specifically designed to assess and document involuntary movements associated with psychotropic medications, making it the most relevant assessment tool in this situation.
A client who is an alcoholic receives a prescription for disulfiram 500 mg PO daily. Which instruction should the nurse provide to this client?
Explanation
A. Disulfiram should be taken each morning, and it is recommended to start it 48 hours after the last drink of alcohol to prevent a severe reaction. This helps establish a clear association between the medication and alcohol avoidance.
B. While taking disulfiram with water is generally advisable, the crucial aspect is the timing and the initial 48-hour abstinence period.
C. Taking the medication at bedtime or limiting alcohol to one ounce daily does not address the specific timing requirement for disulfiram initiation.
D. Beginning the medication immediately and taking it daily, regardless of alcohol consumption, may not establish the necessary 48-hour alcohol-free period before starting disulfiram.
When a male client is asked about his reason for coming to the mental health clinic, he replies, “It all started because I work in a hostile work environment. My boss would not let me go to a religious service, so I went to human resources, and they didn’t want to do anything. It has been a really difficult time for me.” Which response should the nurse provide?
Explanation
A. This question may be perceived as confrontational. It is essential to explore the client's feelings and experiences first.
B. Asking about resignation is premature at this stage. Exploring feelings and experiences is more appropriate initially.
C. This response acknowledges the client's feelings and experiences, allowing for further exploration of the issues that brought him to the clinic.
D. This question is more focused on the client's actions rather than exploring the emotional impact of the events. The nurse should first understand the client's feelings before addressing actions or solutions.
A client is admitted to an inpatient psychiatric unit, and the antipsychotic medication clozapine is prescribed. Which intervention should the nurse include in this client’s plan of care?
Explanation
A. While sore throat and fever can be potential side effects of clozapine, informing UAP is not a proactive intervention. Regular monitoring of white blood cell (WBC) counts is crucial for
detecting clozapine-induced agranulocytosis.
B. Protective isolation is not a standard practice for clients taking clozapine. Monitoring for specific side effects, such as agranulocytosis, is more important.
C. Offering clozapine with food is not a priority intervention for managing potential side effects.
Monitoring and reporting WBC counts take precedence.
D. Clozapine is associated with the risk of agranulocytosis. Regular monitoring of WBC counts is essential, and any findings outside the normal range should be promptly reported to the
healthcare provider.
The nurse is preparing medications for a client with bipolar disorder and notices that the antipsychotic medication was discontinued several days ago. Which medication should also be discontinued?
Explanation
A. Alprazolam is a benzodiazepine used for anxiety and should not necessarily be discontinued solely based on discontinuation of an antipsychotic.
B. Lithium is a mood stabilizer commonly used in bipolar disorder but is not necessarily discontinued with the discontinuation of an antipsychotic.
C. Benztropine is an anticholinergic medication often used to manage extrapyramidal symptoms (EPS) associated with antipsychotic medications. If the antipsychotic is discontinued,
benztropine may also be discontinued.
D. Magnesium is not typically associated with antipsychotic use, and its discontinuation would depend on the specific indication and circumstances.
A client with chronic alcohol dependency is admitted due to a recent relapse. Which findings should the nurse expect this client to exhibit? (Select all that apply)
Explanation
A. Chronic alcohol use is more likely to be associated with increased prothrombin time and partial thromboplastin levels due to impaired liver function.
B. Increased values of serum levels for liver function profile (such as AST, ALT, GGT) are common in individuals with chronic alcohol dependency.
C. Tolerance, where increasingly larger amounts of alcohol are needed to feel drunk, is a characteristic feature of alcohol dependency.
D. Periodic indigestion and negative occult blood in the stool may be indicative of alcohol- related gastrointestinal issues.
E. Memory lapses, especially blackouts or amnesia regarding events that occurred during drinking, are common in chronic alcohol use and dependency.
The nurse assesses a client who recently began experiencing violent nightmares. Which factor in the client’s history should the nurse further explore?
Explanation
A. A family history of dementia may be relevant but is not typically associated with violent nightmares. Alcohol use is more directly related to this symptom.
B. Witness to an accident may be a traumatic experience, but it does not specifically address the symptom of violent nightmares.
C. Alcohol use can contribute to sleep disturbances, including nightmares. Exploring the client's alcohol use is essential in understanding the cause of the nightmares.
D. Inadequate diversional activity is a broad concept and may not be directly related to the specific symptom of violent nightmares.
The nurse observes a client with a history of psychosis repeatedly looking to the side and mumbling responses to no one present in that direction. Which comment is best for the nurse to make?
Explanation
A. Telling the client that the voices are not real may be confrontational and invalidate the client's experiences, which can be counterproductive.
B. Suggesting discussing the experience at a later time is supportive and allows the client to feel heard and understood without dismissing or confronting the hallucination directly.
C. Instructing the client to be calm and focus on something else may be unrealistic and unhelpful in managing hallucinations.
D. Commenting on the client appearing to speak with someone may not be as therapeutic as acknowledging the experience and offering to discuss it later.
While visiting the community mental health center, a client with a diagnosis of major depressive disorder asks the nurse if what is shared with the staff will be shared with family members. How should the nurse respond to this client?
Explanation
A. Providing the client with written information about privacy laws is a good practice, but a verbal explanation is also necessary to address the immediate concern.
B. This response provides accurate information about confidentiality while acknowledging exceptions when safety is at risk.
C. Non-verbal gestures may be ambiguous and could lead to misunderstandings. It's important to communicate clearly with the client.
D. Assuring the client that information will be shared only with the staff may not be entirely accurate, as there are situations where confidentiality must be breached, such as when safety is a concern.
A client with paranoia is admitted to the mental health unit and immediately goes to the corner of the room and sits quietly without communicating. In approaching the client, what intervention should the nurse implement first?
Explanation
A. Showing the client the unit may be overwhelming and not address the immediate need for communication and building rapport.
B. Explaining the nurse's role helps establish trust and provides the client with information about who is present and their purpose.
C. Reading the client his/her rights is important but may be premature and not as immediately relevant as establishing communication.
D. Offering medication should come after establishing communication and assessing the client's needs, as not all clients may require or be ready for medication.
An adolescent male who was arrested a month ago for gang-related activities has a court order to attend weekly group therapy sessions at the mental health clinic. Today his mother calls the clinic nurse to report that her son became angry last night and put his fist through a window. Which intervention is most important for the nurse to implement?
Explanation
A. Advising the mother to call the police if violent behavior occurs again addresses the safety of the client and others and is a necessary step to ensure appropriate intervention.
B. Referring the mother for psychiatric evaluation is important but may not directly address the immediate safety concern related to the recent violent behavior.
C. Reinforcing the need for the adolescent to attend group therapy sessions is relevant, but the immediate focus should be on addressing the safety issue.
D. Telling the mother to describe her feelings may be helpful for therapeutic communication but may not be the most urgent intervention in response to the reported violent behavior.
Which interventions should the nurse include in the plan of care for an adolescent who is depressed? (Select all that apply.)
Explanation
A. Reinforcing statements regarding a will to live and realistic plans for the future is supportive and encourages positive thinking.
B. Discussing the client's suicide plan may not be appropriate and could potentially exacerbate the situation. The focus should be on promoting safety.
C. Limiting time allowed to play video games is a reasonable intervention to prevent isolation and promote engagement in healthier activities.
D. Encouraging the client to discuss thoughts and feelings about wanting to die is essential for therapeutic communication and understanding the depth of the client's distress.
E. Restricting visitors to family members only may be too isolating and may not be necessary unless safety concerns or specific family dynamics dictate such restrictions.
An older man with a history of multiple falls at home tells the clinic nurse that his son, who was incarcerated last year for assault and battery, has become increasingly abusive since his release from prison six weeks ago. Which intervention is most important for the nurse to implement?
Explanation
A. Telling the client to call Adult Protective Services is a valid intervention, but immediate safety planning is crucial.
B. Verifying the client's report by determining physical evidence is important but may not be the most immediate and practical intervention.
C. Referring the client to a program for victims of domestic violence is a valuable option, but immediate safety planning should take precedence.
D. Assisting the client in developing an emergency safety plan is the most important intervention to ensure the client's safety in the present situation.
A female client with obsessive-compulsive personality disorder is admitted to the hospital for a cardiac catheterization. The afternoon before the procedure, the client begins to keep detailed notes of the nursing care she is receiving, and reports her findings to the nurse at bedtime. What action should the nurse implement?
Explanation
A. Explaining that the behavior invades the rights of the nursing staff may be confrontational and not helpful in addressing the client's underlying concerns.
B. Teaching the client strategies to control obsessive-compulsive behavior is a therapeutic approach that promotes self-management.
C. Asking the client to explain may not be as effective as providing guidance on managing the behavior.
D. Encouraging the client to express feelings is important but may not directly address the obsessive-compulsive behavior.
A client with opioid dependence makes a statement to the nurse about desiring to lead a healthier lifestyle by making changes in the next 2 weeks. How should the nurse respond?
Explanation
A. Supporting the client to list small behavioral changes is a person-centered and achievable approach to promote progress.
B. Explaining specific skills needed to prevent a relapse may be overwhelming at this early stage.
C. Providing teaching on symptoms of substance use dependence may not be the most immediate and practical response to the client's expressed desire for positive change.
D. Advising the client to reschedule until committing to recovery is not supportive and may discourage the client's motivation for positive change.
A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words, and wanders into client’s rooms. The nurse decides that the client needs constant observation based on which of these assessment findings?
Explanation
A. Disrupting group activities may be a concerning behavior, but it may not necessarily warrant constant observation.
B. Wandering into client’s rooms poses a safety risk to both the client and others, indicating a need for constant observation to prevent potential harm.
C. Talking with nonsensical words is indicative of disorganized thought processes but may not directly necessitate constant observation for safety.
D. Refusing antipsychotic medications is a concerning behavior, but it alone may not be an immediate safety risk that requires constant observation.
A client diagnosed with schizophrenia has been receiving haloperidol for the past year, and the treatment plan includes moving the client to a lower maintenance dosage. Which intervention should the nurse include in this client’s plan of care? (Select all that apply)
Explanation
A. Shielding the client from direct sunlight is important because some antipsychotic medications, including haloperidol, can increase sensitivity to sunlight, leading to sunburn.
B. Gradually withdrawing the medication over several days is a prudent approach to avoid withdrawal symptoms and potential worsening of symptoms.
C. Enforcing a fluid restriction is not typically necessary during dosage adjustment for antipsychotic medications like haloperidol.
D. Increasing the dosage if the white blood cell count drops is not a standard practice during the dosage adjustment of antipsychotic medications. Monitoring for adverse effects and adjusting the dosage accordingly is important, but the decision should be based on a comprehensive assessment rather than a single laboratory value.
A male client with schizophrenia continues to talk to others on the mental health unit using tangential speech. What intervention should the nurse implement?
Explanation
A. Telling the client to discuss his ideas when his thoughts are more clear may not be effective as it does not provide immediate guidance on improving communication.
B. Teaching the client to slow down and focus on the topic by listening to his words is a therapeutic intervention to address tangential speech and promote effective communication.
C. Asking the client to repeat his comments may not directly address the issue of tangential speech and may not be as therapeutic as providing guidance on communication techniques.
D. Confronting the client when he talks rapidly may be perceived as confrontational and may not be the most therapeutic approach to address tangential speech.
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