HESI Case Studies--Psychiatric/Mental
Health-Psychosis (Adam Monroe)
1. Which thought process describes the client's inability to leave his apartment
because he thought someone was waiting to kill him?
Delusions
2. When the client explains that someone has been following him and is waiting
outside the door of the ED, how should the nurse respond?
"You must be concerned, but you are safe here,"
3. Which term fits the nurse's observation that the client looks to the corner of the
room and mumbles to himself?
Hallucinations
4. When the client looks around the room and mumbles to himself, how should
the nurse respond?
"Are you hearing voices?"
5. The client admits that the voices he hears have been getting louder over the
past couple of weeks. Which question should the nurse ask next?
"What do the voices say?"
6. Which medication(s) should the nurse anticipate giving the client after securing
a prescription from the healthcare provider? (Select all)
-Short-acting anxiolytic (benzodiazepines)
-Antipsychotic medication
7. Which assessment data provides evidence that Brian can be involuntarily
committed to the hospital, if he insists on leaving?
Losing 10 pounds in 2 weeks
8. What is the most important part of this admission process?
Take away Brian's cigarettes and lighter
9. Which assessment data are the best indicators of the potential for violence?
(Select all)
-Past suicide attempts
-History of violence
-Medication noncompliance
10. The nurse understands that the purpose of the urine drug screen is to assess
Brian for what important information?
Detection of substances that may have caused Brian's delusions and/or hallucinations
11. Which lab value(s) from the urinalysis can the nurse expect to be related to
Brian's 10 pound weight loss in the past 2 weeks? (Select all)
-Positive ketones
-Increased urine specific gravity
12. What is the purpose of a baseline complete blood count (CBC) prior to
initiation of the antipsychotic medication?
To monitor if other conditions are present
13. Which nursing diagnosis is best to include in the initial care plan?
Sensory-perceptual alteration related to withdrawal into self
Health-Psychosis (Adam Monroe)
1. Which thought process describes the client's inability to leave his apartment
because he thought someone was waiting to kill him?
Delusions
2. When the client explains that someone has been following him and is waiting
outside the door of the ED, how should the nurse respond?
"You must be concerned, but you are safe here,"
3. Which term fits the nurse's observation that the client looks to the corner of the
room and mumbles to himself?
Hallucinations
4. When the client looks around the room and mumbles to himself, how should
the nurse respond?
"Are you hearing voices?"
5. The client admits that the voices he hears have been getting louder over the
past couple of weeks. Which question should the nurse ask next?
"What do the voices say?"
6. Which medication(s) should the nurse anticipate giving the client after securing
a prescription from the healthcare provider? (Select all)
-Short-acting anxiolytic (benzodiazepines)
-Antipsychotic medication
7. Which assessment data provides evidence that Brian can be involuntarily
committed to the hospital, if he insists on leaving?
Losing 10 pounds in 2 weeks
8. What is the most important part of this admission process?
Take away Brian's cigarettes and lighter
9. Which assessment data are the best indicators of the potential for violence?
(Select all)
-Past suicide attempts
-History of violence
-Medication noncompliance
10. The nurse understands that the purpose of the urine drug screen is to assess
Brian for what important information?
Detection of substances that may have caused Brian's delusions and/or hallucinations
11. Which lab value(s) from the urinalysis can the nurse expect to be related to
Brian's 10 pound weight loss in the past 2 weeks? (Select all)
-Positive ketones
-Increased urine specific gravity
12. What is the purpose of a baseline complete blood count (CBC) prior to
initiation of the antipsychotic medication?
To monitor if other conditions are present
13. Which nursing diagnosis is best to include in the initial care plan?
Sensory-perceptual alteration related to withdrawal into self
