Mental Health (PSYCH) HESI - PRACTICE 2021/2022 Exam

The nurse is discussing the grieving process with the client. Which stages are included in Kubler-Ross' stages of grief? Rank in the correct order. 1. Acceptance 2. Bargaining 3. Denial 4. Anger 5. Depression - coomplete answersAnswer: 3. Denial 4. Anger 2. Bargaining 5. Depression 1. Acceptance Which situation requires priority intervention on an inpatient psychiatric unit? 1. A client is threatening to throw the television at another client. 2. A male client wants to use the phone to call his spouse. 3. A client sitting in a chair is delusional and hallucinating 4. A client has refused to eat anything for the last 2 days. - coomplete answersAnswer: 1. A client is threatening to throw the television at another client. The client diagnosed with bipolar disorder and who is prescribed lithium, an anti mania medication, is admitted to the psychiatric unit in an acute manic state. Which intervention should the nurse implement first? 1. Have the laboratory draw a STAT serum lithium level. 2. Evaluate what behavior prompted the psychiatric admission. 3. Assess and treat the client's physiological needs. 4. Administer STAT dose of lithium to the client. - coomplete answersAnswer: 3. Assess and treat the client's physiological needs. The psychiatric unit staff is upset about the new female charge nurse who just sits in her office all day. One of the staff members informs the clinical manager indicates a laissez-faire leadership style? 1. "I will schedule a meeting to discuss the concerns of the charge nurse." 2. "I hired the new charge nurse and she is doing what I told her to do." 3. "You and the staff really should take care of this situation on your own." 4. "I will talk to the charge nurse about your concerns and get back to you." - coomplete answersAnswer: 3. "You and the staff really should take care of this situation on your own." (laissez-faire attitude is an "everybody is driving their own train" attitude, you guys take care of it)(option 1. is democratic. 2. is an autocratic style. authoritarian approach. 4. is taking charge of the situation.) The mental health worker reports that one of the nurses threatened to force-fed the male client diagnosed with schizophrenia if the client did not eat the meal on the lunch tray. Which action should the charge nurse take first? 1. Tell the MHW that this intervention is part of the client's care plan. 2. Request the nurse to come to the office and discuss the MHW allegation. 3. Ask the client what happened between him and the nurse during lunch. 4. Ask the MHW to write down the situation to submit to the head nurse. - coomplete answersAnswer: 2. Request the nurse to come to the office and discuss the MHW allegation. (never choose an answer like 4. where it suggests you "pass it up" so that you don't have to deal with the problem. it will be wrong) The client diagnosed with paranoid schizophrenia is imminently aggressive and is dangerous to himself, the other clients, and the psychiatric staff members. The client is placed in a seclusion room. Which interventions should the psychiatric nurse implement? Select all that apply. 1. Assess the client every 2 hours for side effects of medication. 2. Tell the client what behavior will prompt the release from seclusion. 3. Do not notify the client's family of the initiation of seclusion. 4. Explain that the client will be in seclusion room for 24 hours. 5. Instruct the MHW to check the client every 10-15 minutes. - coomplete answersAnswer: 1. Assess the client every 2 hours for side effects of the medication., 2. Tell the client what behavior will prompt the release from seclusion., 5. Instruct the MHW to check the client every 10-15 minutes. The psychiatric nurse overhears a MHW arguing with a client diagnosed with paranoid schizophrenia. Which action should the nurse implement? 1. Ask the MHW to go to the nurse's station. 2. Tell the MHW to quit arguing with the client. 3. Notify the clinical manager of the psychiatric unit. 4. Report the behavior to the client abuse committee. - coomplete answersAnswer: 1. Ask the MHW to go to the nurse's station. (first thing you are going to do is assess situation with the MHW.) The psychiatric nurse has taken 15 minutes extra for the lunch break two times in the last week. Which action should the female clinical manager implement? 1. Take no action and continue to watch the nurse's behavior. 2. Document the behavior in writing and place in the nurse's file. 3. Tell the nurse to check in and out with her when taking lunch. 4. Talk to the nurse informally about taking 45 minutes for lunch. - coomplete answersAnswer: 4. Talk to the nurse informally about taking 45 minutes for lunch. (Assess) The client diagnosed with Alzheimer's disease is on a special unit for clients with cognitive disorders. Which assessment data would warrant immediate intervention by the psychiatric nurse? 1. The client does not know his or her name, date, or place. 2. The client is unable to dress himself or herself without assistance. 3. The client is difficult to arouse from sleep. 4. The client needs assistance when eating a meal. - coomplete answersAnswer: 3. The client is difficult to arouse from sleep. The mother of a client recently diagnosed with schizophrenia says to the nurse, "I was afraid of my son. Will he be alright?" Which response by the psychiatric nurse supports the ethical principal of veracity? 1. "I can see your fear; you are concerned your son will not be alright." 2. "If your son takes medication, the symptoms can be controlled." 3. "Why were you afraid of your son? Did you think he would hurt you?" 4. "Schizophrenia is a mental ill ness and your son will not be alright." - coomplete answersAnswer: 2. "If your son takes medication, the symptoms can be controlled." (veracity means to tell the truth. 1. is a therapeutic response. 3. don't ask the pt why or what made you. 4. opposite of veracity, that is not true. The client in the psychiatric unit tells a nurse, "Someone just put a bomb under the couch in the lobby." Which action should the nurse implement first? 1. Look under the couch for a bomb. 2. Implement the bomb scare protocol. 3. Have the staff evacuate the unit. 4. Tell the client there is not a bomb. - coomplete answersAnswer: 1. Look under the couch for a bomb. (Assess) The head nurse in a psychiatric unit in the county emergency department is assigning client to the staff nurses. Which client should be assigned to the most experienced nurse? 1. The client who is crying and upset because she was raped. 2. The client diagnosed with bipolar disorder who is agitated. 3. The client who was found wandering the streets in a daze. 4. The client diagnosed with schizophrenia who is hallucinating. - coomplete answersAnswer: 3. The client who was found wandering the streets in a daze. (when the Q asks "who are you going to give to the most experienced nurse" what they are really asking is "who is the most unstable." "who requires the most in-depth assessment and teaching?" we know what is wrong with all of these patients, besides #3., we only know the client was found walking in a daze, we don't know anything about them) the client diagnosed with anorexia is refusing to eat and is less than 20% of ideal body weight for her height and structure. The client has not eaten anything since admission 2 days ago. Which action should the nurse implement? 1. Notify the psychiatrist to request a court order to feed the client. 2. Take no action because the client has the right to refuse treatment. 3. Discharge the client because she is not complying with the treatment. 4. Physically restrain the client and insert a nasogastric tube for feeding. - coomplete answersAnswer: 1. Notify the psychiatrist to request a court order to feed the client. The nurse answers the client's phone in the lobby area and the person asks, "May I speak to Mr. Jones?" Which action should the nurse implement? 1. Ask the caller who is asking for Mr. Jones. 2. Tell the caller Mr. Jones cannot have phone calls. 3. Request the caller to give the access code for information. 4. Find Mr. Jones and tell them he has a phone call. - coomplete answersAnswer: 4. Find Mr. Jones and tell them he has a phone call. (This is the client's phone. Facility phone would be different.) The client being the psychiatric nurse in the mental health clinic tells the nurse "If I tell you something very important, will you promise not to tell anyone?" Which statement is the nurse's best response? 1. "I promise I will not tell anyone if you don't want me to." 2. "If it affects your care I will have to tell someone who can help." 3. "If you don't want me to tell anyone, then please don't tell me." 4. "Why do you not want me to tell anyone if it is so important?" - coomplete answersAnswer: 2. "If it affects your care I will have to tell someone who can help." (1. don't promise anything. 3. do not shut a pt down when they are trying to communicate. 4. never ask a pt "why" or "what made you".) Which situation would warrant immediate intervention by the charge nurse on the psychiatric unit after receiving the a.m. shift report? 1. The client diagnosed with paranoid schizophrenia who is delusional. 2. The p.m. shift licensed practical nurse called in to say that he or she would not be in for work today. 3. The male mental health worker reports losing his unit key and identification card. 4. The unit secretary has HCP's orders that need to be co-signed. - coomplete answersAnswer: 3. The male mental health worker reports losing his unit key and identification card. (The unit is no longer secure. Pt's safety is at risk.) A highly agitated client paces the unit and states. "I could buy and sell this place." The client's mood fluctuates rom fits of laughter to outbursts of anger. Which is the most accurate documentation of this client's behavior? A. "Rates mood 8/10. Exhibiting looseness of association. Euphoric." B. "Mood euthymic. Exhibiting magical thinking. Restless." C. "Mood labile. Exhibiting delusions of reference. Hyperactive." D. "Agitated and pacing. Exhibiting grandiosity. Mood labile." - coomplete answersAnswer: D. "Agitated and pacing. Exhibiting grandiosity. Mood labile." A client diagnosed with bipolar disorder is distraught over insomnia experienced over the last 3 nights and a 12- pound weight loss over the past 2 weeks. Which should be this client's priority nursing diagnosis? A. Knowledge deficit R/T bipolar disorder AEB concern about symptoms. B. Altered nutrition: Less than body requirements r/t hyperactivity AEB weight loss. C. Risk for suicide r/t powerlessness AEB insomnia and anorexia. D. Altered sleep patterns r/t mania AEB insomnia for the past 3 nights. - coomplete answersAnswer: B. Altered nutrition: Less than body requirements r/t hyperactivity AEB weight loss. (physical needs/health always priority.) A nurse is planning care for a client diagnosed with bipolar disorder: manic phase. In which order should the nurse prioritize the client outcomes in the exhibit? Client outcomes: 1. Maintains nutritional status. 2. Interacts appropriately with peers. 3. Remains free from injury. 4. Sleeps 6-8 hrs at night. - coomplete answersAnswer: 3., 1., 4., 2. A client diagnosed with bipolar disorder: depressive phase intentionally overdoses on sertraline (Zoloft). Family members report that the client has experience anorexia, insomnia, and recent job loss. What should be the priority nursing diagnosis for this client? A. Risk for suicide r/t hopelessness. B. Anxiety: severe r/t hyperactivity C. Imbalanced nutrition: less than body requirements r/t refusal to eat D. Dysfunctional grieving r/t loss of employment. - coomplete answersAnswer: A. Risk for suicide r/t hopelessness. A client diagnosed with BP disorder: manic episode refuses to take lithium carbonate due to excessive weight gain. in order to increase compliance, which medication should a nurse anticipate that a physician will prescribe? A. Sertraline (Zoloft)