RN HESI Mental Health Exam.
Total Questions : 42
Showing 25 questions, Sign in for moreA client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?
Explanation
A. Shifting attention from self to others might strain the individual further as they might not have the emotional energy for it.
B. Relaxation without addressing underlying issues won't help in managing depression and might exacerbate the situation.
C. Focusing on small achievable tasks helps in breaking down overwhelming problems into manageable parts, aiding in a sense of accomplishment.
D. Ventilating emotions might be beneficial, but solely relying on this strategy might not address the core issue of handling responsibilities.
A female college student is admitted to the mental health unit following a drug overdose. The student tells the nurse that she took the overdose following the end of a romantic relationship. Which is the primary goal for hospitalization that should be included in this client's plan of care?
Explanation
A. Returning to a previous level of functioning is essential for someone hospitalized due to an overdose as it ensures their safety and stability.
B. Identifying personal traits might be a part of therapy but is not the primary goal immediately after an overdose.
C. While exercise can be beneficial, it's not the primary concern right after a suicide attempt.
D. Discussing relationship needs is important but not the immediate priority after a suicide attempt.
A female college student is admitted to the mental health unit following a drug overdose. The student tells the nurse that she took the overdose following the end of a romantic relationship. Which is the primary goal for hospitalization that should be included in this client's plan of care?
Explanation
A. Returning to a previous level of functioning is essential for someone hospitalized due to an overdose as it ensures their safety and stability.
B. Identifying personal traits might be a part of therapy but is not the primary goal immediately after an overdose.
C. While exercise can be beneficial, it's not the primary concern right after a suicide attempt.
D. Discussing relationship needs is important but not the immediate priority after a suicide attempt.
When the nurse addresses questions to an adult female client who is depressed, the client's responses are delayed. Which intervention should the nurse include in this client's plan of care?
Explanation
A. Initiating an exercise program might be helpful, but it doesn't directly address the delayed responses or aid in communication.
B. Asking the client to describe her depression might be beneficial, but it may not be suitable if the client's responses are delayed.
C. Spending time in silence with the client can create a safe and supportive environment, allowing the client to communicate at her own pace without feeling pressured.
D. Observing for signs of psychosis is important but doesn't directly address the delayed responses.
A client reports needing to increase opioid dosage to achieve the original level of pain relief. Which action should the nurse take?
Explanation
A. Explaining the phenomenon of opioid tolerance and receptor response reduction with continued use helps the client understand why increased dosage might be needed.
B. Collecting information on opioid sources is important but doesn't directly address the issue of increased tolerance.
C. Detoxification might be an extreme measure and is not the first step in addressing increased opioid tolerance.
D. Discussing the dangers of opioid misuse is essential, but it doesn't address the specific issue of increased tolerance for pain relief.
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 should the nurse provide to this client?
Explanation
A. This response may invalidate the client's feelings and might not provide reassurance about the nurse's support.
B. This response deflects the client's statement and might not address the client's feelings of being cared for.
C. This response acknowledges the client's feelings, reinforces the presence of the nursing team, and emphasizes the collective goal of helping the client get better.
D. This response might indirectly question the client's perception and doesn't directly address the client's need for reassurance and support.
Following the visit, what are appropriate actions for the nurse? Select all that apply.
Explanation
A. Mailing education items to the home for batterer treatment options might not be appropriate without the client's consent or discussion.
B. Providing referrals for mental health services aligns with addressing the client's needs.
C. Following up with the client in a few weeks ensures continuity of care and monitoring of the client's progress.
D. Calling the police as a mandatory reporter might be necessary if there's an immediate threat, but it's not mentioned in the scenario.
E. Documenting verbatim statements about the abuse is crucial for accurate record-keeping and legal purposes.
An antidepressant medication is prescribed for a client who reports sleeping only four hours in the past two days and a weight loss of nine pounds within the last month. Which client goal is most important to achieve within the first three days of treatment?
Explanation
A. Understanding the purpose of the medication regimen is important but might not be the most immediate concern.
B. Improving sleep to at least six hours a night addresses the client's reported insomnia and supports their physical well-being.
C. Describing the reasons for hospitalization might be essential for the client's understanding but might not have the immediate urgency.
D. Meeting the scheduled appointment with the dietitian is important for nutritional concerns but might not directly address the client's reported sleep and weight loss within the first three days of treatment.
A client with schizophrenia returns to the clinic two weeks after receiving a prescription for haloperidol. To assess for neuroleptic malignant syndrome (NMS), which information is most important for the nurse to obtain during this visit?
Explanation
A. White blood cell count might be relevant for other conditions but is not specific to NMS.
B. 24-hour urinary output might help evaluate kidney function but is not specific to NMS.
C. Blood sugar level might be important but is not the primary indicator of NMS.
D. Vital signs, such as temperature, blood pressure, heart rate, and respiratory rate, are crucial in assessing for NMS as it typically presents with changes in these parameters.
A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. Which action should the nurse implement?
Explanation
A. Involving another nurse might not necessarily address the client's guarded and suspicious behavior.
B. Documenting the behavior is important for the client's records, but it doesn't address the immediate need for assessment.
C. Postponing the interview might not resolve the client's guarded behavior and could delay necessary assessment.
D. Attempting to ask the client simple questions allows for a non-threatening approach and might gradually build rapport, encouraging the client to engage in conversation.
The nurse is admitting a male client who takes lithium carbonate twice a day. Which information should the nurse report to the healthcare provider immediately?
Explanation
A. A five-pound weight gain could be significant but might not require immediate reporting unless it continues to increase rapidly.
B. A depressed affect is concerning but may not warrant immediate reporting unless it signals a severe change in the client's mental state.
C. Nausea and vomiting could indicate lithium toxicity, a serious side effect requiring immediate attention and evaluation by the healthcare provider.
D. Short-term memory loss can be a side effect of lithium but might not pose an immediate threat unless severe or rapidly worsening.
The nurse plans to use role-playing as a therapeutic measure. Which individual is most likely to benefit from this type of therapeutic intervention?
Explanation
A. Role-playing might not be suitable for a hyperactive 4-year-old with potential autism, as their attention span and ability to engage in structured activities might be limited.
B. Adolescents often benefit from role-playing to navigate social situations and address feelings of rejection or lack of acceptance from peers.
C. Role-playing might not be as effective for an older adult in a long-term care facility who takes others' belongings, as this behavior may require different interventions.
D. While role-playing can be helpful for individuals with schizophrenia, their tendency to refuse medications might not necessarily be addressed through this method.
A client with a history of alcoholism is admitted for detoxification. Based on treatment protocol, the nurse gives the client a dose of lorazepam 6 mg. Which additional prescription should the nurse administer immediately?
Explanation
A. Haloperidol might be used in some detoxification scenarios but isn't directly indicated based on the information provided.
B. Folic acid is not an immediate medication administered during alcohol detoxification.
C. Trazodone is used for other purposes and is not an immediate medication in alcohol detoxification.
D. Vitamin B1 (thiamine) supplementation is crucial during alcohol detoxification to prevent Wernicke-Korsakoff syndrome or other neurological complications associated with
alcohol withdrawal.
When responding to a call light, the nurse finds a client with aggressive behaviors pacing and restless in the room. The client shouts, "What took you so long to get in here!" Which action should the nurse implement?
Explanation
A. Providing personal space allows the client to feel less threatened and gives them room to express their emotions without feeling cornered.
B. Standing in the doorway might block the client's exit and could escalate the situation.
C. Requesting backup might be necessary in some situations but should not be the initial response to the client's agitation.
D. Encouraging the client to sit down might not be well-received and could escalate the situation further.
A young female client is admitted to the emergency room because she was raped that evening by her date. Which computer documentation should the nurse enter in the electronic medical record as the client's chief complaint?
Explanation
A. "Client has been sexually assaulted" is a formal and concise description. However, it isn’t written as a client would say it which is a key requirement in documentation of the presenting complaint.
B. "Client reported that she had sexual relations against her will" might be accurate but doesn't convey the severity of the situation as clearly as the term "sexually assaulted."
C. "Client claims that she was forced to participate in sexual intercourse" might describe the situation but doesn't necessarily reflect the urgency or trauma of the incident.
D. "Client states, 'My date raped me tonight'" is documented in the client’s own words and is descriptive enough to be the presenting complaint.
A male client tells the nurse that he does not want to take the atypical antipsychotic drug olanzapine because of the side effects he experienced when he took the drug for a year. Which experience is most likely related to taking olanzapine?
Explanation
A. Thoughts of wanting to hurt himself might be associated with various mental health conditions or medications but aren't specifically linked to olanzapine.
B. Diarrhea is a less common side effect of olanzapine and is not among the more frequently reported side effects.
C. Weight gain is a well-known side effect of olanzapine, with substantial increases reported in some cases.
D. Altered liver function tests are less commonly associated with olanzapine use compared to weight gain.
A client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. Which intervention is best for the nurse to implement?
Explanation
A. Isolating the client might exacerbate feelings of social exclusion and isn't the best approach for managing echolalia.
B. Administering a sedative should not be the initial response to echolalia unless the behavior poses immediate harm to the client or others.
C. Escorting the client to a private area can help reduce the annoyance to other clients without isolating or punishing the individual.
D. Avoiding recognition of the behavior doesn't address the issue and might negatively impact the therapeutic relationship.
The nurse is caring for a client who is experiencing extreme sadness after the passing of a companion of 30 years. The client describes not being able to think of other things and finds it difficult to control emotions. Which action should the nurse take first?
Explanation
A. Exploring changes in life after the loss can help the nurse understand the client's current situation and provide a basis for further interventions.
B. Suggesting psychiatric consultation might be necessary but might not be the immediate first step without assessing the client's current needs.
C. Offering a referral to pastoral counseling might be helpful, but understanding the client's current state is important before making specific referrals.
D. Encouraging attendance at a local support group could be beneficial but might not be the immediate priority without understanding the client's current emotional state.
A female client with bulimia is admitted to the mental health unit after she disclosed to a friend that she purges after meals. Which intervention should the nurse implement first?
Explanation
A. Discussing alternative strategies is important but might not be the initial priority without first assessing the client's physical health.
B. Providing a supportive environment for meals is crucial, but assessing the client's physical status should take precedence.
C. Monitoring for vomiting after meals is important, but a comprehensive assessment of physical health should come first.
D. Assessing weight, vital signs, and electrolytes is crucial in determining the client's current physical health status and any potential risks associated with bulimia.
A client with post-traumatic stress disorder (PTSD) is admitted to the psychiatric unit. Which intervention is most important for the nurse to include in this client's plan of care?
Explanation
A. Providing a quiet room is important. This is because individuals with PTSD are often hypersensitive to noise and other stimuli, which can trigger flashbacks or other
symptoms. A quiet environment can help to reduce anxiety and promote relaxation.
B. Acquainting the client with the unit rules is important, but connecting the client with peers who understand their experiences can be more therapeutic initially.
C. Ensuring a well-balanced diet is essential but might not be the priority in the immediate plan of care for someone newly admitted with PTSD.
D. Introducing the client to others with similar diagnoses helps foster a sense of belonging.
However, this is a long-term rather than an immediate intervention.
A female client engages in repeated checks of door and window locks and behavior that prevents her from arriving on time and interfering with her ability to function effectively. Which action should the nurse take?
Explanation
A. Discussing checking the time might not address the underlying behavior but could be explored as part of understanding the client's routines.
B. Determining the locks' type and size might be relevant but might not address the behavior's root cause.
C. Planning daily activities is important and can help her manage her time effectively.
D. Asking the client why she checks the locks may not hep in addressing the underlying issue.
The nurse is planning the care for a client who is hospitalized with bipolar disorder. The client wanders the hallways, talks excessively, and makes sexual comments about the staff. Which intervention(s) should the nurse include in the plan of care? (Select all that apply.)
Explanation
A. Inviting for a walk when the client's energy is high can help channel excess energy and reduce restlessness.
B. Engaging the client in competitive activities might escalate the situation and isn't suitable for managing hyperactivity in bipolar disorder.
C. Assigning the client to a single room can reduce external stimuli and potentially decrease overstimulation that might contribute to the behavior.
D. Providing television programs with suspense might not effectively engage the client or address their needs.
E. Giving concise and firm directions for hygiene and dressing can help provide structure and guidance during times of excessive energy or impulsivity.
A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and lack of motivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?
Explanation
A. Developing a list of pleasurable activities might be beneficial but might not directly address the lack of motivation and psychomotor retardation.
B. Encouraging exercise is generally helpful but might be challenging for someone experiencing hypersomnia and lack of motivation.
C. Providing education on methods to enhance sleep is important, but it might not directly address psychomotor retardation or motivation.
D. Teaching the client to develop a plan for daily structured activities can provide a sense of purpose, routine, and help combat psychomotor retardation and lack of motivation commonly seen in depression.
An adolescent client is admitted to the postoperative unit following open reduction of a fractured femur which occurred when the client fell down the stairs at a party. The nurse notices needle marks on the client's arms. Which assessment findings should the nurse document related to suspected narcotic withdrawal?
Explanation
A. Vomiting, seizures, and loss of consciousness are severe manifestations but not commonly associated with narcotic withdrawal.
B. Depression, fatigue, and dizziness are symptoms commonly associated with depression but not specifically with narcotic withdrawal.
C. Hypotension, shallow respirations, and dilated pupils are more indicative of opioid overdose rather than withdrawal.
D. Agitation, sweating, and abdominal cramps are common symptoms of narcotic withdrawal.
A young adult client with a recent diagnosis of bipolar disorder takes lithium carbonate daily. The client informed the school nurse of the desire to live away from home to attend college after graduating in one month. Which information is most important for the nurse to provide the client and his family?
Explanation
A. Awareness of signs and symptoms is important, but routine evaluation of lithium levels is crucial for those taking lithium carbonate due to its narrow therapeutic range and potential toxicity.
B. Monitoring serum lithium levels is essential to ensure the medication remains within the therapeutic range and to prevent potential lithium toxicity.
C. Participating in therapy can be beneficial but might not be as critical as monitoring lithium levels for someone newly diagnosed with bipolar disorder.
D. While independence is important, the key concern here is the need for close monitoring of lithium levels due to the medication's potential side effects.
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