HESI RN MENTAL HEALTH V2

HESI RN MENTAL HEALTH V2 1. A client with depression remains in bed most of the day, declines activities and refuses meals. Which nursing problem has the greatest priority for this client? a. Loss of interest in diversional activity. b. Social isolation c. Refusal to address nutritional needs d. Low self-esteem. 2. 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? a. Lithium (lithotabs ) b. Benztropine (Cogentin) c. Alprazolam (Xanax) d. Magnesium (milk of magnesia) 3. A female client request that her husband be allowed to stay in the room during the admission assessment. While interviewing the client, the nurse notes a discrepancy between the client’s verbal and nonverbal communication. What action should the nurse take? a. Pay close attention and document the nonverbal messages b. Ask the client’s husband to interpret the discrepancy c. Ignore the nonverbal behavior and focus on the client’s verbal messages. d. Integrate the verbal and nonverbal messages and interpret them as one. 4. A male client approaches the nurse with an angry expression on his face and raises his voice, saying, “My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out!” the nurse recognizes that the client is using which defense mechanism? a. Denial b. Projection c. Rationalization d. Splitting 5. A male client with bipolar disorder who began taking lithium carbonate five days ago is complaining of excessive thirst, and the nurse finds him attempting to drink water from the bathroom sink faucet. Which intervention should the nurse implement? a. Report the client’s serum lithium level to the healthcare provider b. Encourage the client to suck on hard candy to relieve the symptoms c. No actions is needed since polydipsia is a common side effect d. Tell the client that drinking from the faucet is not allowed 6. The nurse is teaching a client about the initiation of a prescribed abstinence therapy using disulfiram (Antabuse). What information should the client acknowledge understanding? a. Completely abstain from heroin or cocaine use b. Remain alcohol free from 12 hours prior to the first dose c. Attend monthly meetings of alcoholics anonymous d. Admit to others that he is a substance abuser 7. A male client with schizophrenia is admitted to the mental health unit after abruptly stopping his prescription for ziprasidone (Geodon) one month ago. Which question is most important for the nurse to ask the client a. Have you lost interest in the things that you used to enjoy? b. Is your ability to think or concentrate decreased? c. How many continuous hours do you sleep at night d. Do you hear sounds or voices that others do not hear? 8. During an annual physical by the occupational nurse working in a corporate clinic, a male employee tells the nurse that his high-stress job is causing trouble in his personal life. He further explains the he often gets so angry while driving to and from work that he has considered “getting even” with other drivers, how should the nurse respond? a. “anger is contagious and could result in major confrontation” b. “Try not to let your anger cause you to act impulsively” c. “expressing your anger to a stranger could result in an unsafe” d. It sound as if there are many situations that make you feel angry” 9. A client who has agoraphobia (a fear of crowds) is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care? a. Encourage substitution of positive thoughts for negative ones b. Establish trust by providing a calm, safe environment c. Progressively expose the client to larger crowds d. Encourage deep breathing when anxiety escalates in a crowd 10. A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone (Risperdal). When the client walks to the nurse’s station in a literally contracted position, he states that something has made his body confort into a monster. What action should the nurse take? a) Medicate the client with the prescribed antipsychotic thioridazine (mellaril) b) Offer the client a prescribed physical therapy hot pack for muscle spasms. c) Direct client to occupational therapy to distract him from somatic complaints. d) Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia. 11. 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? A) Is attempting to physically restrain the client. B) Tells the client to go to the quiet area of the unit. C) Is using a loud voice to talk to the client. D) Remains at a distance of 4 feet from the client. 12. A client on the mental health unit is becoming more agitated, shouting at the staff, and pacing in the hallway. When a PRN medication is offered, the client refuses the medication and defiantly sits on the floor in the middle of the unit hallway. What nursing intervention should the nurse implement first? A) Transport of the client to the seclusion room B) Quietly approach the client with additional staff members. C) Take other client in the area to the client lounge. D) Administer medication to chemically restrain the client. 13. A client is admitted to the mental health unit and reports taking extra antianxiety medication because, “I’m so stressed out. I just wanted to go sleep” the nurse should plan one-on- one observation of the client based on which statement? A) What should I do? Nothing seems to help.” B) I have been so tired lately and needed to sleep.” C) I really think that I don’t need to be here.” D) I don’t want to talk. Nothing matters anymore.” 14. A male hospital employee is pushed out of the way by a female employee because of an oncoming gurney. The pushed employee becomes very angry and swings at the female employee. Both employees are referred for counseling with the staff psychiatric nurse. Which factor in the pushed employee’s history is most related to the reaction that occurred? A) Is worried about losing his job to a woman B) Tortured animals as a child. C) Was physically abused by his mother D) Hates to be touched by anyone 15. The nurse documents the mental status of a female client who has been hospitalized for several days by court order. The client state, “I don’t need to be here” and tells the nurse that she believes that the television talks to her. The nurse should document these assessment findings in which section of the mental status exam? A) Level of concentration B) Insight and judgment C) Remote memory D) Mood and affect 16. The nurse on the evening shift receives report that a client is scheduled for electroconvulsive treatment (ECT) in the morning. Which intervention should the nurse implement the evening before the scheduled ECT? A) Hold all bedtime medication. B) Keep the client NPO after midnight. C) Implement elopement precautions. D) Give client an enema at bedtime. 17. A client who is admitted to the mental health unit report shortness of breath and dizziness. The client tells the nurse, “I feel like I’m going to die” which nursing problem should the nurse include in this client’s plan of care? A) Mood disturbance B) Moderate anxiety C) Altered thoughts D) Social isolation 18. A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confuse. The nurse also determines that the client is homeless and slightly suspicious. This client’s treatment plan should include what priority problem? A) Self-care deficit. B) Disturbed sensory perception. C) Ineffective community coping. D) Acute confuse. 19. A nurse 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? (Select all that apply) A) Have a bag ready that has extra clothes for self and children. B) Establish a code with family and friend to signify violence. C) Purchase a gun to use for protection D) Take a self-defense course that retaliate the abuser with injury. E) Plan an escape route to use if the abuser blocks the main exit. 20. A female client, who is wearing dirty clothes and has a foul body odor, comes to the clinic reporting feeling scared because she is being stalked. What A) Offer the client a safe place to relax before interviewing her. B) Ask the client to describe why she is being stalked. C) Recommend that the client talk with a social worked. D) Assure client that the healthcare provider will see her today. 21. The nurse leading a group session of adolescent client gives the members a handout about anger management. One of the male clients is fidgety, interrupts peers when they try to talk, and talks about his pets at home. What nursing action is best for the nurse to take? A) Explore the client’s feelings about his pet and home life. B) Encourage his peers to help involve him in the activity. C) Give the client permission to leave and return in 10 min. D) Redirect him by encouraging him to read from the handout. 22. A male adolescent was admitted to the unit two days ago for depression. When the mental health nurse tries to interview the client to establish rapport, he becomes very irritated and sarcastic. Which action is best for the nurse to take? A) Report the behavior to the next shift. B) Offer to play a game of cards with the client. C) Document the behavior in the chart. D) Plan to talk with the client the next day. 23. A male adult is admitted because of an acetaminophen (Tylenol) overdose. After transfer to mental health unit the client is told he has liver damage. Which information is most important for the nurse to include in the client’s a discharge plan? A) Eat a high carbohydrate, low fat, low protein diet.