HESI RN MENTAL HEALTH:Question &Answer
100%Correct
-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?
( Answer)
Explain the nurse's role to the client
-client treated with lithium for bipolar develops diarrhea, vomiting and drowsiness, what action should the
nurse do( Answer)Notify HCP of the symptoms prior to the next admin of the drug)
-A mental health worker (MHW) is caring for a client with escalating aggressive behavior, which action
by the MHW warrants immediate intervention by the nurse
( Answer)
Is attempting to physically restrain the client.
-woman who is bipolar is wearing low cut blouse, and skirt with no underwear, what does nurse do?
( Answer)
Walk her to room and help her pick out something more appropriate
-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
( Answer)
What is your biggest concern?
-Woman is diagnosed with breast cancer and she becomes dependent and asks family members if they can
do ADL's that she is fully capable of doing. What is the reason for this behavior?
( Answer)
Its expected; regression is a natural start for recovery
-Patient having to get treated for benzodiazepam and methadone overdose. What do you use?
( Answer)
Narcan
-Patient watching TV starts talking loud to himself. The nurse comes in and can't distract him so turns
down the TV. What should the nurse do then?
( Answer)
Move client to quieter room
-In group therapy the charge nurse notices a client increasing to severe levels of anxiety. What should the
nurse do?
( Answer)
Talk in a calm, approaching manner
-A chronic depressed older man refuses to leave his room. His family moved away to a further location so
they're not able to visit him as much. What approach should the nurse take with this man?
, ( Answer)
May I lay with you for a little?
-Patient who is really depressed and won't talk or communicate, later is energetic and talkative. What
should the nurse do?
( Answer)
Closely monitor the patient (could be suicidal
-Patient who had generalized anxiety disorder on Xanax long-term. What is the outcome?
( Answer)
Importance of not quickly stopping the drug
-Mother has a 9-month old baby with mental issues and growth issues. The mother comes in and says
she's depressed because she'll never have a normal baby. What should the nurse say?
( Answer)
Have you had any thoughts of harming your baby or yourself?
-Lithium level 1.5. What do you tell the client who had a recent suicide attempt after seeing him become
very anxious after hearing his Lithium levels?
( Answer)
drink 2-3L of water in 24 hours
-Woman comes into ED having been raped by her date. What should the nurse document
( Answer)
document she stated "I was raped by my date"
-Which patient would require CAGE assessment?
( Answer)
Alcohol patient, cut down, annoyed, guilty, eye opener
-A nurse is changing a dressing on a bipolar patient's stomach from self-inflicting knife wound. What is
the nurse's best approach?
( Answer)
showing no signs of being judgmental
-Woman is at a meeting with you, what is important for the nurse to document after hearing her issues in
the relationship
( Answer)
get spouses statement as well
-patient in corner with paranoid symptoms, staring and watching you. They refused to communicate with
you. What do you do?
( Answer)
ask simple questions
-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?
( Answer)
Tangential thinking
-A depressed adolescent becomes sarcastic and irritates when you start to ask him questions. What does
100%Correct
-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?
( Answer)
Explain the nurse's role to the client
-client treated with lithium for bipolar develops diarrhea, vomiting and drowsiness, what action should the
nurse do( Answer)Notify HCP of the symptoms prior to the next admin of the drug)
-A mental health worker (MHW) is caring for a client with escalating aggressive behavior, which action
by the MHW warrants immediate intervention by the nurse
( Answer)
Is attempting to physically restrain the client.
-woman who is bipolar is wearing low cut blouse, and skirt with no underwear, what does nurse do?
( Answer)
Walk her to room and help her pick out something more appropriate
-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
( Answer)
What is your biggest concern?
-Woman is diagnosed with breast cancer and she becomes dependent and asks family members if they can
do ADL's that she is fully capable of doing. What is the reason for this behavior?
( Answer)
Its expected; regression is a natural start for recovery
-Patient having to get treated for benzodiazepam and methadone overdose. What do you use?
( Answer)
Narcan
-Patient watching TV starts talking loud to himself. The nurse comes in and can't distract him so turns
down the TV. What should the nurse do then?
( Answer)
Move client to quieter room
-In group therapy the charge nurse notices a client increasing to severe levels of anxiety. What should the
nurse do?
( Answer)
Talk in a calm, approaching manner
-A chronic depressed older man refuses to leave his room. His family moved away to a further location so
they're not able to visit him as much. What approach should the nurse take with this man?
, ( Answer)
May I lay with you for a little?
-Patient who is really depressed and won't talk or communicate, later is energetic and talkative. What
should the nurse do?
( Answer)
Closely monitor the patient (could be suicidal
-Patient who had generalized anxiety disorder on Xanax long-term. What is the outcome?
( Answer)
Importance of not quickly stopping the drug
-Mother has a 9-month old baby with mental issues and growth issues. The mother comes in and says
she's depressed because she'll never have a normal baby. What should the nurse say?
( Answer)
Have you had any thoughts of harming your baby or yourself?
-Lithium level 1.5. What do you tell the client who had a recent suicide attempt after seeing him become
very anxious after hearing his Lithium levels?
( Answer)
drink 2-3L of water in 24 hours
-Woman comes into ED having been raped by her date. What should the nurse document
( Answer)
document she stated "I was raped by my date"
-Which patient would require CAGE assessment?
( Answer)
Alcohol patient, cut down, annoyed, guilty, eye opener
-A nurse is changing a dressing on a bipolar patient's stomach from self-inflicting knife wound. What is
the nurse's best approach?
( Answer)
showing no signs of being judgmental
-Woman is at a meeting with you, what is important for the nurse to document after hearing her issues in
the relationship
( Answer)
get spouses statement as well
-patient in corner with paranoid symptoms, staring and watching you. They refused to communicate with
you. What do you do?
( Answer)
ask simple questions
-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?
( Answer)
Tangential thinking
-A depressed adolescent becomes sarcastic and irritates when you start to ask him questions. What does
