Hesi Mental Health Questions
by Henry G January 24, 2019
HESIHeath
Mental MENTAL HEALTH
Questions QUESTIONS AND ANSWERS
!. Which technique is the most important therapeutic tool a nurse should us
to provide quality care to a psychiatric client?
#. Self-analysis. Correct
$. Counter transference.
%. Therapeutic self-disclosure.
Self-analysis is a tool for the nurse to examine oneself, view one's responses i
various mental and emotional moments, and provide a sense of how sensitive
care should be provided relative to one's own needs, so (B) is a primary tool
used by the nurse to establish therapeutic empathy and achieve authentic,
open, and personal communication with a client. Although (A, C, and D) may
occur in a nurse-client relationship, they may not contribute to establishing a
therapeutic relationship.
#. The nurse completes an emergency admission of a male client with
schizophrenia who has not been taking his antipsychotic medications. The
client is pacing, is extremely irritable, and has a blood pressure of 146/96.
What is the priority nursing action?
!. Encourage the client to stop pacing and sit down.
#. Reevaluate the client's blood pressure in an hour. Correct
$. Direct the client to attend recreational therapy.
%. Review the client's baseline blood pressure.
The client is irritable and pacing, which can contribute to the elevated BP, so
reevaluation of the client's BP in an hour (B) allows time for the excitement and
stress of the admission process to abate. (A) is likely to increase the client's
agitated state. Recreational therapy (C) provides another environmental
stimulus, which can contribute to the client's anxiety. (D) is helpful, but the mo
immediate action is to retake the blood pressure in one hour.
,!. Drugs taken in last 7 days. Correct
#. Family history of suicide.
$. Usual coping mechanisms.
%. Frequency of anxiety attacks.
Use of prescribed, over-the-counter, and illicit drugs (A) is the most important
information to obtain when planning care because drugs are likely to influence
the client's behavior and ability to cope with stressful situations. (B, C, and D)
are worthwhile assessment findings, but they do not have the priority of (A).
%. The nurse is planning care for a client with major depression who is
admitted to the unit after a recent suicide attempt. Which intervention has
the highest priority for inclusion in this client's plan of care?
!. Search the client's personal belongings. Correct
#. Introduce the client to others on the unit.
$. Ask the client about recent stressful events.
%. Move to a room that allows close observation.
To ensure that the client has not acquired some means to inflict self harm, a
routine search of personal belongings (A), which is a common safety measure
and policy, should be implemented until the client stabilizes and suicidal
ideations abate. (B) is a component of the therapeutic milieu, but the client's
readiness to interact with others should be assessed first. Although recent
stressors (C) may have precipitated the suicide attempt, it is more important t
ensure the client's safety from self-harm. Close observation should be initiate
(D), but it is most important that any hazardous items are removed from the
client's possession.
^. A 6-year-old girl with severe birth defects and mental retardation is broug
to the emergency room because of a broken arm. The caregiver reports th
the girl sustained the injury when she fell from her wheelchair. Which
intervention is most important for the nurse to implement?
, The nurse should evaluate the child for other injuries because a 6-year-old ch
with a low-level fall that results in a fracture should be considered a possible
victim of child abuse, until proven otherwise (C). (A) has a lower priority than
(C). (B) is not within the scope of nursing practice and should be referred to
someone who is an expert. (D) is unrealistic.
6.An older client is admitted to a psychiatric hospital with the diagnosis, "Majo
depression, single episode." Which laboratory value is most important for the
nurse to report to the healthcare provider immediately?
!. Increased serum creatinine level.
#. Positive rapid plasma reagin (RPR).
$. Increased thyroid stimulating hormone (TSH). Correct
%. Elevated serum calcium level.
The healthcare provider should be notified of (C) immediately. An increased T
suggests a low thyroxine level because the TSH is trying to stimulate thyroxine
production, and hypothyroidism symptoms mimic those of depression. (A) oft
increases with aging. (B) is indicative of syphilis and should be reported, but
does not have the priority of (C). (D) has implications for other illnesses, such
non-Hodgkin's lymphoma or hyperparathyroidism.
^. The daughter of a 79-year-old male client tells the nurse that her father is
becoming increasingly forgetful. Which finding indicates that the client
needs further evaluation of cognitive function?
!. Repeats the same stories to different family members or friends.
#. Cannot mentally retrace objects that were recently misplaced. Correct
$. Cannot remember instructions to program an electronic device.
%. Forgets a planned event, then remembers the event a short while later.
Inability to retrace misplaced objects (B) is an indicator of possible cognitive
impairment that requires further assessment. (A, C, and D) are examples of
benign forgetfulness.
by Henry G January 24, 2019
HESIHeath
Mental MENTAL HEALTH
Questions QUESTIONS AND ANSWERS
!. Which technique is the most important therapeutic tool a nurse should us
to provide quality care to a psychiatric client?
#. Self-analysis. Correct
$. Counter transference.
%. Therapeutic self-disclosure.
Self-analysis is a tool for the nurse to examine oneself, view one's responses i
various mental and emotional moments, and provide a sense of how sensitive
care should be provided relative to one's own needs, so (B) is a primary tool
used by the nurse to establish therapeutic empathy and achieve authentic,
open, and personal communication with a client. Although (A, C, and D) may
occur in a nurse-client relationship, they may not contribute to establishing a
therapeutic relationship.
#. The nurse completes an emergency admission of a male client with
schizophrenia who has not been taking his antipsychotic medications. The
client is pacing, is extremely irritable, and has a blood pressure of 146/96.
What is the priority nursing action?
!. Encourage the client to stop pacing and sit down.
#. Reevaluate the client's blood pressure in an hour. Correct
$. Direct the client to attend recreational therapy.
%. Review the client's baseline blood pressure.
The client is irritable and pacing, which can contribute to the elevated BP, so
reevaluation of the client's BP in an hour (B) allows time for the excitement and
stress of the admission process to abate. (A) is likely to increase the client's
agitated state. Recreational therapy (C) provides another environmental
stimulus, which can contribute to the client's anxiety. (D) is helpful, but the mo
immediate action is to retake the blood pressure in one hour.
,!. Drugs taken in last 7 days. Correct
#. Family history of suicide.
$. Usual coping mechanisms.
%. Frequency of anxiety attacks.
Use of prescribed, over-the-counter, and illicit drugs (A) is the most important
information to obtain when planning care because drugs are likely to influence
the client's behavior and ability to cope with stressful situations. (B, C, and D)
are worthwhile assessment findings, but they do not have the priority of (A).
%. The nurse is planning care for a client with major depression who is
admitted to the unit after a recent suicide attempt. Which intervention has
the highest priority for inclusion in this client's plan of care?
!. Search the client's personal belongings. Correct
#. Introduce the client to others on the unit.
$. Ask the client about recent stressful events.
%. Move to a room that allows close observation.
To ensure that the client has not acquired some means to inflict self harm, a
routine search of personal belongings (A), which is a common safety measure
and policy, should be implemented until the client stabilizes and suicidal
ideations abate. (B) is a component of the therapeutic milieu, but the client's
readiness to interact with others should be assessed first. Although recent
stressors (C) may have precipitated the suicide attempt, it is more important t
ensure the client's safety from self-harm. Close observation should be initiate
(D), but it is most important that any hazardous items are removed from the
client's possession.
^. A 6-year-old girl with severe birth defects and mental retardation is broug
to the emergency room because of a broken arm. The caregiver reports th
the girl sustained the injury when she fell from her wheelchair. Which
intervention is most important for the nurse to implement?
, The nurse should evaluate the child for other injuries because a 6-year-old ch
with a low-level fall that results in a fracture should be considered a possible
victim of child abuse, until proven otherwise (C). (A) has a lower priority than
(C). (B) is not within the scope of nursing practice and should be referred to
someone who is an expert. (D) is unrealistic.
6.An older client is admitted to a psychiatric hospital with the diagnosis, "Majo
depression, single episode." Which laboratory value is most important for the
nurse to report to the healthcare provider immediately?
!. Increased serum creatinine level.
#. Positive rapid plasma reagin (RPR).
$. Increased thyroid stimulating hormone (TSH). Correct
%. Elevated serum calcium level.
The healthcare provider should be notified of (C) immediately. An increased T
suggests a low thyroxine level because the TSH is trying to stimulate thyroxine
production, and hypothyroidism symptoms mimic those of depression. (A) oft
increases with aging. (B) is indicative of syphilis and should be reported, but
does not have the priority of (C). (D) has implications for other illnesses, such
non-Hodgkin's lymphoma or hyperparathyroidism.
^. The daughter of a 79-year-old male client tells the nurse that her father is
becoming increasingly forgetful. Which finding indicates that the client
needs further evaluation of cognitive function?
!. Repeats the same stories to different family members or friends.
#. Cannot mentally retrace objects that were recently misplaced. Correct
$. Cannot remember instructions to program an electronic device.
%. Forgets a planned event, then remembers the event a short while later.
Inability to retrace misplaced objects (B) is an indicator of possible cognitive
impairment that requires further assessment. (A, C, and D) are examples of
benign forgetfulness.
