HESI RN MENTAL HEALTH
Middle age female with no previous mental illness and the family states that she is having paranoid
thoughts, pt states: "I want to find out why people are stalking me".
Therapeutic response: "it sounds like this experience is frightening for you"
Pt is mad at mom for turning him in and wants mom to bring belongings and does not want to talk to
her. What action does the nurse need to take before the visit?
Discuss methods of clear communication
Duty to warn question: Pt tells the nurse that he wants to kill his boss, nurse tells healthcare provider,
healthcare provider tells his boss. What disciplinary action is needed?
None. The action was appropriate
Defense mechanism question: for projection
"I am here because the police said I did something wrong"
pt with stress admits to taking care of the ex-husband 's parents. Which defense mechanism is this?
Regression
therapeutic Milieu: Pt had a recent suicide attempt after his wife offered divorce, lost his job, and his
best friend moved away. What is the best nursing intervention to support therapeutic Milieu ?
Encourage activities that will allow him to take control over his environment
Interview noting taking question
arrange the setting and decrease any stimuli
Prep from D/C from the psychic unit, what should the nurse include ?
Explore that pt's feelings regarding the discharge
People in a group home and they are wiping feces on the wall. What is the nurse's highest priority?
Infection control
Pt refuses to take medications and in defiance sits in the middle of the hallway floor. Best nursing
action?
To move other clients to another room
Nurse and client trade roles: nurse demonstrates bad behavior of the client. Why is this important?
Role play assists the client to recognize their own behavior
Pt states, "I don't know, I just can't think". What is the best activity by the nurse?
Set daily goals
, Adolescent interrupts group to talk about pets during group therapy. Best nursing action?
Redirect him with a handout
Crisis intervention: male client feeling stressed, increased anger over the last month. What is an
appropriate nursing action?
Ask to identify problems that have occurred during the last month
Pt discharged after diening suicide thoughts to the healthcare provider. Pt mutters as walking towards
the door, " Now I can kill myself". What is the best nursing action?
Notify the HCP and stop the patient from leaving
Long term care client who is anxious and agitated. What is the best nursing action?
decrease stimuli by lowering the TV volume
Elderly pt anxious about procedure. What is the best nursing action?
Encourage the pt to express their feelings about the procedure
Agoraphobia question: Highest priority question:
To establish trust by providing a calm, safe environment
Agoraphobia question: client afraid to leave house due to fear of open places. What is the nursing
diagnosis?
Anxiety related to real or perceived fear
OCD: a client that continues to wash hands for 2 hours. What is the priority nursing intervention?
To set limits
OCD: a client that keeps cleaning windows. What should you do?
Give a list of activities
A pt with PTSD after rape who displays a detached effect. Best action from nurse?
To ask if they are thinking about harming themselves
PTSD: what should you include in the plan of care?
to provide a quiet room away from a recreational area
conversion disorder: Pt with new onset of blindness, what would suggest a conversion reaction?
No organic correlation to symptoms
Borderline personality disorder: Splitting question
Client's view people as all good or all bad
Middle age female with no previous mental illness and the family states that she is having paranoid
thoughts, pt states: "I want to find out why people are stalking me".
Therapeutic response: "it sounds like this experience is frightening for you"
Pt is mad at mom for turning him in and wants mom to bring belongings and does not want to talk to
her. What action does the nurse need to take before the visit?
Discuss methods of clear communication
Duty to warn question: Pt tells the nurse that he wants to kill his boss, nurse tells healthcare provider,
healthcare provider tells his boss. What disciplinary action is needed?
None. The action was appropriate
Defense mechanism question: for projection
"I am here because the police said I did something wrong"
pt with stress admits to taking care of the ex-husband 's parents. Which defense mechanism is this?
Regression
therapeutic Milieu: Pt had a recent suicide attempt after his wife offered divorce, lost his job, and his
best friend moved away. What is the best nursing intervention to support therapeutic Milieu ?
Encourage activities that will allow him to take control over his environment
Interview noting taking question
arrange the setting and decrease any stimuli
Prep from D/C from the psychic unit, what should the nurse include ?
Explore that pt's feelings regarding the discharge
People in a group home and they are wiping feces on the wall. What is the nurse's highest priority?
Infection control
Pt refuses to take medications and in defiance sits in the middle of the hallway floor. Best nursing
action?
To move other clients to another room
Nurse and client trade roles: nurse demonstrates bad behavior of the client. Why is this important?
Role play assists the client to recognize their own behavior
Pt states, "I don't know, I just can't think". What is the best activity by the nurse?
Set daily goals
, Adolescent interrupts group to talk about pets during group therapy. Best nursing action?
Redirect him with a handout
Crisis intervention: male client feeling stressed, increased anger over the last month. What is an
appropriate nursing action?
Ask to identify problems that have occurred during the last month
Pt discharged after diening suicide thoughts to the healthcare provider. Pt mutters as walking towards
the door, " Now I can kill myself". What is the best nursing action?
Notify the HCP and stop the patient from leaving
Long term care client who is anxious and agitated. What is the best nursing action?
decrease stimuli by lowering the TV volume
Elderly pt anxious about procedure. What is the best nursing action?
Encourage the pt to express their feelings about the procedure
Agoraphobia question: Highest priority question:
To establish trust by providing a calm, safe environment
Agoraphobia question: client afraid to leave house due to fear of open places. What is the nursing
diagnosis?
Anxiety related to real or perceived fear
OCD: a client that continues to wash hands for 2 hours. What is the priority nursing intervention?
To set limits
OCD: a client that keeps cleaning windows. What should you do?
Give a list of activities
A pt with PTSD after rape who displays a detached effect. Best action from nurse?
To ask if they are thinking about harming themselves
PTSD: what should you include in the plan of care?
to provide a quiet room away from a recreational area
conversion disorder: Pt with new onset of blindness, what would suggest a conversion reaction?
No organic correlation to symptoms
Borderline personality disorder: Splitting question
Client's view people as all good or all bad
