-RN MENTAL HEALTH
HESI NCLEX-RN MENTAL HEALTH PRACTICE
1. The nurse reviews the laboratory findings for a client's urine drug screen that
is positive for cocaine. Which client behavior should be expected during
cocaine withdrawal?
A. Psychomotor agitation
B. Restlessness and hyperactivity
C. Detachment from reality and drowsiness
D. Distorted perceptions and hallucinations
Rationale:
During cocaine withdrawal, the nurse should expect option A and a pattern of
withdrawal symptoms similar to those of one who uses amphetamines. Options B,
C, and D are signs and symptoms of a person who is high on cocaine rather than
one who is experiencing withdrawal from cocaine.
2. A middle-aged adult was discharged from a treatment center 6 weeks ago
following treatment for suicide ideation and alcohol abuse. In a follow-up visit to
the mental health clinic, the client complains of lethargy, apathy, irritability, and
anxiety. Which question is most important for the nurse to ask?
A. "Are you taking prescribed antidepressants?"
B. "How much alcohol do you consume daily?"
C. "What seems to precipitate the anxious feelings?"
D. "How many hours do you sleep per day?"
Rationale:
First, and most importantly, the client's use of alcohol should be determined
because further treatment is dependent on the client's sobriety, and asking how
much alcohol is being consumed is a better question than asking if the client is
drinking, which is a "yes-no" answer that does not promote dialogue. Options A,
C, and D provide worthwhile assessment data, but first the nurse should determine
,-RN MENTAL HEALTH
if
, -RN MENTAL HEALTH
the client is still drinking because all efforts to treat symptoms associated with
depression are diminished if the client is still consuming alcohol.
3. A 25-year-old client has been particularly restless, and the nurse finds the client
trying to leave the psychiatric unit. The client tells the nurse, "Please let me go! I
must leave because the secret police are after me." Which response is best for
the nurse to make?
A. "No one is after you. You're safe here."
B. "You'll feel better after you have rested."
C. "I know you must feel lonely and frightened."
D. "Come with me to your room, and I will sit
with you."
Rationale:
Option D is the best response because it offers support without judgment or
demands. Option A is challenging the client's delusion. Option B is offering false
reassurance. Option C is a violation of therapeutic communication because the
nurse is telling the client how she or he feels (frightened and lonely), rather than
allowing the client to describe his or her own feelings. Hallucinating and
delusional clients are not capable of discussing their feelings, particularly when
they perceive a crisis.
4. A client who is being treated with lithium carbonate for manic depression begins
to develop diarrhea, vomiting, and drowsiness. Which action should the nurse
take?
A. Notify the health care provider immediately
and force fluids.
B. Prior to giving the next dose, notify the health
care provider of these symptoms.
, -RN MENTAL HEALTH
C. Record the symptoms and continue with
medication as prescribed.
D. Hold the medication and refuse to
administer additional doses.
Rationale:
Although these are expected symptoms, the
health care provider should be notified prior to
the next administration of the drug. Early side
effects of lithium carbonate (occurring with
serum lithium levels below 2 mEq/L) generally
follow a progressive pattern, beginning with
diarrhea, vomiting, drowsiness, and muscular
weakness (option C). At higher levels, ataxia,
tinnitus, blurred vision, and large dilute urine
output may occur. Option A will lower the
lithium level. Option D is not warranted.
5. A nurse working in the emergency department of a children's hospital admits a
child whose injuries could have been the result of abuse. Which statement most
accurately describes the nurse's responsibility in cases of suspected child
abuse?
A. Obtain objective data such as radiographs
before reporting suspicions.
B. Confirm suspicions of abuse with the health care
provider.
C. Report any case of suspected child abuse.
D. Document injuries to confirm suspected abuse.
HESI NCLEX-RN MENTAL HEALTH PRACTICE
1. The nurse reviews the laboratory findings for a client's urine drug screen that
is positive for cocaine. Which client behavior should be expected during
cocaine withdrawal?
A. Psychomotor agitation
B. Restlessness and hyperactivity
C. Detachment from reality and drowsiness
D. Distorted perceptions and hallucinations
Rationale:
During cocaine withdrawal, the nurse should expect option A and a pattern of
withdrawal symptoms similar to those of one who uses amphetamines. Options B,
C, and D are signs and symptoms of a person who is high on cocaine rather than
one who is experiencing withdrawal from cocaine.
2. A middle-aged adult was discharged from a treatment center 6 weeks ago
following treatment for suicide ideation and alcohol abuse. In a follow-up visit to
the mental health clinic, the client complains of lethargy, apathy, irritability, and
anxiety. Which question is most important for the nurse to ask?
A. "Are you taking prescribed antidepressants?"
B. "How much alcohol do you consume daily?"
C. "What seems to precipitate the anxious feelings?"
D. "How many hours do you sleep per day?"
Rationale:
First, and most importantly, the client's use of alcohol should be determined
because further treatment is dependent on the client's sobriety, and asking how
much alcohol is being consumed is a better question than asking if the client is
drinking, which is a "yes-no" answer that does not promote dialogue. Options A,
C, and D provide worthwhile assessment data, but first the nurse should determine
,-RN MENTAL HEALTH
if
, -RN MENTAL HEALTH
the client is still drinking because all efforts to treat symptoms associated with
depression are diminished if the client is still consuming alcohol.
3. A 25-year-old client has been particularly restless, and the nurse finds the client
trying to leave the psychiatric unit. The client tells the nurse, "Please let me go! I
must leave because the secret police are after me." Which response is best for
the nurse to make?
A. "No one is after you. You're safe here."
B. "You'll feel better after you have rested."
C. "I know you must feel lonely and frightened."
D. "Come with me to your room, and I will sit
with you."
Rationale:
Option D is the best response because it offers support without judgment or
demands. Option A is challenging the client's delusion. Option B is offering false
reassurance. Option C is a violation of therapeutic communication because the
nurse is telling the client how she or he feels (frightened and lonely), rather than
allowing the client to describe his or her own feelings. Hallucinating and
delusional clients are not capable of discussing their feelings, particularly when
they perceive a crisis.
4. A client who is being treated with lithium carbonate for manic depression begins
to develop diarrhea, vomiting, and drowsiness. Which action should the nurse
take?
A. Notify the health care provider immediately
and force fluids.
B. Prior to giving the next dose, notify the health
care provider of these symptoms.
, -RN MENTAL HEALTH
C. Record the symptoms and continue with
medication as prescribed.
D. Hold the medication and refuse to
administer additional doses.
Rationale:
Although these are expected symptoms, the
health care provider should be notified prior to
the next administration of the drug. Early side
effects of lithium carbonate (occurring with
serum lithium levels below 2 mEq/L) generally
follow a progressive pattern, beginning with
diarrhea, vomiting, drowsiness, and muscular
weakness (option C). At higher levels, ataxia,
tinnitus, blurred vision, and large dilute urine
output may occur. Option A will lower the
lithium level. Option D is not warranted.
5. A nurse working in the emergency department of a children's hospital admits a
child whose injuries could have been the result of abuse. Which statement most
accurately describes the nurse's responsibility in cases of suspected child
abuse?
A. Obtain objective data such as radiographs
before reporting suspicions.
B. Confirm suspicions of abuse with the health care
provider.
C. Report any case of suspected child abuse.
D. Document injuries to confirm suspected abuse.
