HESI- Mental Health Exam 2022

A child states "My dad used to drink a beer a day, now he drinks at least a six-pack a day." What can the nurse determine from this statement? Answer- parent is exhibiting tolerance to alcohol 2 days after admission from alcohol withdrawal what should the nurse do? Answer- monitor HR and BP DO NOT IMPLEMENT SEIZURE PADS Something about a male client threatening a teacher or becomes upset with teacher Answer- methods of clearly communicating *** Patient says I'm going to shoot myself" Answer- stop client from leaving the unit History of alcoholism admitted for detoxification; 6mg of Ativan what additional prescription administer immediately Answer- vitamin B1 (thiamine) PTSD admitted to psychiatric unit, which intervention is most important for plan of care Answer- provide quiet room, away from rec area Chronically depressed older male client of a long term care facility becomes more reclusive and today refuses to leave room Answer- may i sit with you for a while? Male client on atypical antipsychotic drug olanzapine(Zyprexa) Adverse reaction is weight gain Answer- client sitting in corner of day room during admission assessment, what nursing action? ask client simple questions How do you take Antabuse? Answer- each morning beginning 48 hours after your last drink of alcohol The nurse is using the CAGE questionnaires as a screening tool for a client who is seeking help because his wife said he had a drinking problem. What information should the nurse explore indepth with the client based on this screening tool? A. Consumption, liver enzyme, gastrointestinal complains and bleeding. B. Minimizes drinking frequently misses family events, guilt about drinking, and amount of daily intake. C. Cancer screening results, anger, gastritis, daily alcohol intake. D. Efforts to cut down, annoyance with questions, guilt, drinking as an "Eye-opener". Answer- D. Efforts to cut down, annoyance with questions, guilt, drinking as an "Eye-opener". (Cutting down, annoyance, guilt and eye-opener drinking are represented with the acronym of CAGE) A client who is admitted with a closed head injury after a gall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the nurse identify as the priority? A. Place in a side-lying position with head of bed elevated. B. Administer disulfram (Atabuse ) immediately C. Give lorezapam (Ativan)PRN for signs of withdrawal. D. Provide thiamine and folate supplements as prescribed. Answer- A (Maintain patient's airwat is the priority for a client who is intoxicated and obtunded) The nurse is preparing medications for a client with bipolar disorder and notices that the antipsychotic medication was discontinued several day ago. Which medication should also be discontinued?A. Alprazolam (Xanax) B. Benztropine (Cogentin) C. Magnesium (Milk of Magneisa) D. Lithium (Lathotbabs) Answer- B (Cogentin is given with traditional antipsychotic medications to reduce extrapyramidal side effects and should be discontinued when the antipsychotic medication is discontinued) The nurse leading a group session of adolescent clients give the members 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. Give the client permission to leave and return in 10 minutes. B. Explore the client's feeling about his pets and home life. C. Encourage his peers to help involve him in the activity. D. Redirect him by encouraging him to read from the handout. Answer- D. Redirect him by encouraging him to read from the handout. (Best nursing action is to ask the client to read from the handout) 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 laterally 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. Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia. D. Direct client to occupational therapy to distract him from somactic complaints. Answer- C (The client is experiencing a dystonic reaction due to dopamine depletion, one of the physiologic actions of Risperidone. This side effect requires immediate management with Cogentin ) A middle-aged adult with major depressive disorder suffer from psychomotor redardation, hypersomnia, and amotivation. Which intervention is like to be most effective in returning this client to a normal level of functioning? A. Encourage the client to exercise. B. Suggest that the client develop a list of pleasurable activities. C. Provide education on methods to enhance sleep. D. Teach the client to develop a plan for daily structured activities. Answer- D. Teach the client to develop a plan for daily structured activities. (Development of structure life-style is vital when a client is having difficulty with psychomotor retardation, amotivation and hypersomnia) A male client with a long history of alcohol dependency arrives in the Emergency department describing the feeling of bugs crawling on his body. His blood pressure is 170/102, pulse rate is 110 beats/ min, and his blood alcohol level is 0 mg/dl. Which prescription should the nurse administer? A. Haloperidol (Hadol) B. Thiamine (Vitamin B1) C. Lorazapam (Ativan) D. Diphenhydramine (Benadryl) Answer- C (A client with a history of alcohol dependency can experience delirium tremors within 72 to 96 hours after alcohol abstinence. Ativan should be given to decrease central venous systems excitation (restlessness, agitation, seizures) 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. Attend monthly meetings of alcoholic anonymous. C. Remain alcohol free for 12 hours prior to the first dose. D. Admit to others that he is a substance abuser. Answer- C (The client must be alcohol free for 12 hours before the beginning of Antabuse therapy to avoid the precipitation of a dusulfiram reaction, an aversive effects) A female client reports feeling hopeless and is unable to stop crying. She explains that she is worried about losing her job. Since the client's husband recently lost his job she feels her employmemt is essential to the family's survival. To evaluate the effectiveness of cognitive-behavioral techniques, which client outcomes should the nurse include in the plan of care? A. Relates insight into problematic relationships B. Demonstrates a healthy relationship with husband. C. Described how the family can resolve problem. D. Changes thought patterns related to problem solving. Answer- D (Cognitive-behavior therapy focuses on changing thought pattern by directing the client to problem solving the present situation) A female client engages in repeated checks of door and window locks, behavior that presents her from arriving on time and interferes with her ability to function effectively. What action should the nurse take? A. Discuss checking the time frequently B. Ask the client why she checks the locks C. Plan a list of activities to be carried out daily. D. Determine the type and size of the locks. Answer- C (Helps the client to gain recognition of and insight into the anxiety and assists her to learn new adaptive coping behaviors) A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. That intervention is best for the nurse to implement? A. avoid recognizing the behavior. B. Isolate the client from other clients. C. Administer a PRN sedative. D. Escort the client to his room. Answer- D (Echolalia, constantly repeating what others are saying, can become disruptive to a community environment, so the nurse should direct the client to a private space such as his room) A young adult male is hospitallizaed due to depression and an attempted suicide attempt. The client reports that he lost his job and was angry with his employer for firing him when he took an overdose of pain medications. Which behavior best indicates to the nurse that his condition is improving? A. Initiates interactions with other clients. B. Describes verbally when he is angry C. Participates in a job search with a social worker. D. Denies plans to harm himself or others. Answer- A (The best indicator of improvement in a client with depression is initiated interaction with others because such behavior indicates that the client is less withdrawn and more self-directed) The nurse is completing the admission assessment of an underweight adolescent who is admitted to a psychiatric unit with a diagnosis of depression. Which finding requires notification to the healthcare providers A. Body mass index of 21 B. Potassium level of 2.9 mEq/dl C. WBC of 10,000 mm3 D. Blood pressure of 110/70 mmHg. Answer- B ( The nurse should inform the healthcare provider of potassium level of 2.9 mEq/dl, which could be caused by electrolyte imbalance) Following involvement in a motor vehicles collision, a middle-aged adult client is admitted to the hospital with multiple facial fractures, The client's bold alcohol level is high on admission. Which PRN prescription should be administered if the client begin to exhibits signs and symptoms of delirium tremors (DT)? A. Hydromorphone (Dilaudid) 2mg IM B. Prochloperazine (Compazine) 5mg IM C. Chlopronmazine (Thorazine) 50 mg IM D. Lorazepam (Ativan) 2mg IM. Answer- D (Ativan is often used to treat DT and of the PRN prescriptions listed, is the treatment of choice) A female client, who is wearing dirty clothes and has afoul body odor, comes to the clinic reporting feeling scared because she is being stalked. What action is most important for the nurse to take? A. Assure client that the healthcare provider will see her today. B. Recommend that the client talk with a social worker. C. Ask the client to describe why she is being stalked. D. Offer the client a safe place to relax before interviewing her. Answer- D (The client is demonstrating fear related to an underlying metal disorder, and she needs to feel safe before anything is required of her) A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit's day room. What action should the nurse implement first? A. Administer a PRN sedative. B. Sit in the chair next to the client. C. Escort the client to his room. D. Listen to what the client is saying. Answer- D (Auditory hallucination can have various meanings to the client. Listening to what the client is saying helps the nurse determine the type of response that is required based on the hallucinatory messages the client is receiving) A teenager who has lost 20 pounds in the last three months is admitted to the hospital with hypotension and tachycardia. The client reports irregular menses and hair loss. Which intervention is most important for the nurse to include in the clients plans of care? A. Initiate caloric and nutritional therapy. B. Implement behavioral modification therapy. C. Evaluate the client for low self-esteem. D. Record daily weights and graft trend. Answer- A (The client presents with evidence of anorexia nervosa resulting from self-starvation, which is a life-threatening condition. Providing nutrition and calories is the priority intervention so that the risk of electrolyte imbalance and severed dehydration can be reduced) The nurse is developing unit policies that will include nursing guidelines for maintaining a therapeutic milieu. Which interventions should be included when providing a therapeutic milieu in an inpatient setting? A. Opportunities to contribute to one's treatment plan. B. One on one dialogue sessions with the therapist. C. Regularly scheduled unit activities for peer interaction. D. Home visits to reintergrate into the family. Answer- C (The nurse is responsible for maintaining a therapeutic milieu which provides a secire and structure environment that promotes client's safety, provide opportunities for the client to learn healthy coping skills) After receiving treatment for anorexia, a student asks the school nurse for permission to work in the school cafeteria as part of the school's work study program. What action should the nurse take? A. Recommend assignment to the receptionist's office. B. Suggest that the student work in the athletic department. C. Refer the student to a psychiatrist for further discussion. D. Determine the parent's opinion of the work assignment Answer- A (Client with anorexia are obsessed with food and exercise, which often trigger self indulgence. Assignment to the receptionist's office decreases the opportunity for the student to be distracted with obsession associated with anorexia) A middle-aged remale client with no previous psychiatric history is seen in the mental health clinic because her family describes her as having paranoid thoughts. On assessment, she tells the nurse "I want to find out why these people are stalking me" which response should the nurse provide? A. "It sounds like this experience is frightening for you" B. "What makes you think people are stalking you?' C. "I know you are frightened, but no one is stalking you" D. "Do you think someone is trying to harm you" Answer- A (The nurse should respond to the client's fear without addressing the delusion.) A male veteran who recently returned from a war zone has post traumatic stress disorder (PTSD) and is admitted to the psychiatric ward because of admitted suicidal ideation. On admission, the client's family informed the HCP that therapy sessions did not seem to be helping. Select only one intervention that as the highest priority? A. Administer paraxeitne 40 mg as prescribed. B. Develop a list of therapy programs. C. Remove all shaving equipment. D. Determine if client has a suicide plan. Answer- C (Keeping the client safe is priority, so suicide precautions should be implemented, C is priority) 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. Offer to play a game of cards with the client. B. Report the behavior to the next shift. C. Document the behavior in the chart. D. Plan to talk with the client the next day. Answer- A (Playing a game with the adolescent will establish rapport because adolescent usually communicate more easily if involve in an activity) Which client statement suggests to the nurse that the client is using the defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit. A. " I am here because the police thought I as doing something wrong" B. "At least I hit the wall instead of hitting the psychiatric aide" C. "I want to be here because I know it is the best psychiatric facility" D. "Don't believe everything my family tells you, I am not crazy" Answer- A (Blaming others for unacceptable desires, thought, shortcomings or mistakes is using the defense mechanism of projection) A female high school teacher who was a child alcoholic parents seeks counseling at the community health clinic because of depression over a student who was killed by a drunk driver. After several weeks of counseling, which client behavior is the best indicator that the client is coping well with anxiety related to the student's dealth? A. Signs a safety contract with the nurse agreeing not to hurt herself or others B. Confront her parents about the hurt she felt as achild of alcoholic parents. C. Becomes the faculty sponsor for Student Against Drunk Driving (SADD) D. Describes alternatives to becoming depressed over the student's death. Answer- C (C is a method if channeling anxiety and denotes an adaptive behavior to a crisis situation) While interviewing a client, the nurse takes notes to assist with accurate documentation later. Which statement is most accurate regarding note-taking during an interview? A. The nurses' ability to directly observe the client's non verbal communication is limited with note takes B. Taking notes during an interview is a legal obligation of the examining nurse. C. The client's comfort level is increased when the nurse breaks eye contact to take note to take note. D. The interview process is enhanced with note taking and allows the client speak at normal pace. Answer- A (Although note-taking is important, particularly when a detailed report is vital to the assessment, note-taking requires a break in eye contact and impedes the nurse's observation of the client's nonverbal behavior) An adolescent make receives a prescription for an antidepressant drug because he is exhibiting a depressed affect. While the client is taking the antidepressant, which comparison of the client's behavior before and after taking the drug is most important for the nurse to obtain? A. His appetite. B. The emotional quality of his attitude C. His level of activity. D. The interactions he has with others. Answer- B (The most important assessment is related to mood or the emotional quality of his attitude so the nurse should assess for the presence of depressed mood and suicide ideation) While setting in the dayroom of the mental health unit, a male adolescent avoids eye contact, looks at the floor, and talks softly when interacting verbally with the nurse. The two trade places, and the nurse demonstrate the client's behavior. What is the main goal of this therapeutic techniques? A. Discuss the client's feeling when he responds. B. Allow the client to identify the way he interacts. C. Initiate a non-threatening conversation with the client. D. Dialog about the ineffectiveness of his interactions. Answer- B (The nurse is using role-playing to help the client identify his behavior when interacting with others, B which provides an opportunity for the client to rehearse assertive interactions) 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. Take other clients in the area to the client lounge. C. Quietly approach the client with additional staff members. D. Administer medication to chemically restrain the client. Answer- B (The most important intervention is to maintain the safety of other clients by removing them rom the proximity of the client who may potentially create a dangerous situation)