HESI review and Mental Health Unit III (CH 12
and 23): 2023/2024 questions and answers, end of
chapter
1. A person has had difficulty keeping a job because of arguing with co-workers and accusing them of
conspiracy. Today the person shouts, they’re all plotting to destroy me. Isn’t that true? Select the nurses
most therapeutic response.
a. Everyone here is trying to help you. No one wants to harm you.
b. Feeling that people want to destroy you must be very frightening.
c. That is not true. People here are trying to help you if you will let them.
d. Staff members are health care professionals who are - ANS - ANS: B
Resist focusing on content; instead, focus on the feelings the patient is expressing. This strategy
prevents arguing about the reality of delusional beliefs. Such arguments increase patient anxiety and the
tenacity with which the patient holds to the delusion. The other options focus on content and provide
opportunity for argument.
2. A newly admitted patient diagnosed with schizophrenia is hyper vigilant and constantly scans the
environment. The patient states, I saw two doctors talking in the hall. They were plotting to kill me. The
nurse may correctly assess this behavior as:
a. echolalia.
b. an idea of reference.
c. a delusion of infidelity.
d. an auditory hallucination. - ANS - ANS: B
Ideas of reference are misinterpretations of the verbalizations or actions of others that give special
personal meanings to these behaviors; for example, when seeing two people talking, the individual
assumes they are talking about him or her. The other terms do not correspond with the scenario.
3. A patient diagnosed with schizophrenia says, my co-workers are out to get me. I also saw two doctors
plotting to kill me. How does this patient perceive the environment?
a. Disorganized
,b. Dangerous
c. Supportive
d. Bizarre - ANS - ANS: B
The patient sees the world as hostile and dangerous. This assessment is important because the nurse
can be more effective by using empathy to respond to the patient. Data are not present to support any
of the other options.
4. When a patient diagnosed with schizophrenia was discharged 6 months ago, haloperidol (Haldol) was
prescribed. The patient now says, I stopped taking those pills. They made me feel like a robot. What are
common side effects the nurse should validate with the patient?
a. Sedation and muscle stiffness
b. Sweating, nausea, and diarrhea
c. Mild fever, sore throat, and skin rash
d. Headache, watery eyes, and runny nose - ANS - ANS: A
Typical antipsychotic drugs often produce sedation and extrapyramidal side effects such as stiffness and
gait disturbance, effects the patient might describe as making him or her feel like a robot. The side
effects mentioned in the other options are usually not associated with typical antipsychotic therapy or
would not have the effect described by the patient.
5. Which hallucination necessitates the nurse to implement safety measures? The patient says,
a. I hear angels playing harps.
b. The voices say everyone is trying to kill me.
c. My dead father tells me I am a good person.
d. The voices talk only at night when I’m trying to sleep. - ANS - ANS: B
The correct response indicates the patient is experiencing paranoia. Paranoia often leads to fearfulness,
and the patient may attempt to strike out at others to protect self. The distracters are comforting
hallucinations or do not indicate paranoia.
6. A patients care plan includes monitoring for auditory hallucinations. Which assessment findings
suggest the patient may be hallucinating?
a. Detachment and overconfidence
b. Darting eyes, tilted head, mumbling to self
,c. Euphoric mood, hyperactivity, distractibility
d. Foot tapping and repeatedly writing the same phrase - ANS - ANS: B
Clues to hallucinations include eyes looking around the room as though to find the speaker, tilting the
head to one side as though listening intently, and grimacing, mumbling, or talking aloud as though
responding conversationally to someone.
7. A health care provider considers which antipsychotic medication to prescribe for a patient diagnosed
with schizophrenia who has auditory hallucinations and poor social function. The patient is also
overweight and hypertensive. Which drug should the nurse advocate?
a. Clozapine (Clozaril)
b. Ziprasidone (Geodon)
c. Olanzapine (Zyprexa)
d. Aripiprazole (Abilify) - ANS - ANS: D
Aripiprazole is a third-generation atypical antipsychotic effective against both positive and negative
symptoms of schizophrenia. It causes little or no weight gain and no increase in glucose, high- or low-
density lipoprotein cholesterol, or triglycerides, making it a reasonable choice for a patient with obesity
or heart disease. Clozapine may produce agranulocytosis, making it a poor choice as a first-line agent.
Ziprasidone may prolong the QT interval, making it a poor choice for a patient with cardiac disease.
Olanzapine fosters weight gain.
8. A patient diagnosed with schizophrenia tells the nurse, I eat skillet. Tend to end. Easter. It blows away.
Get it? Select the nurses’ best response.
a. Nothing you are saying is clear.
b. Your thoughts are very disconnected.
c. Try to organize your thoughts and then tell me again.
d. I am having difficulty understanding what you are saying. - ANS - ANS: D
When a patients’ speech is loosely associated, confused, and disorganized, pretending to understand is
useless. The nurse should tell the patient that he or she is having difficulty understanding what the
patient is saying. If a theme is discernible, ask the patient to talk about the theme. The incorrect options
tend to place blame for the poor communication with the patient. The correct response places the
difficulty with the nurse rather than being accusatory.
9. A patient diagnosed with schizophrenia exhibits little spontaneous movement and demonstrates waxy
flexibility. Which patient needs are of priority importance?
, a. Self-esteem
b. Psychosocial
c. Physiological
d. Self-actualization - ANS - ANS: C
Physiological needs must be met to preserve life. A patient with waxy flexibility must be fed by hand or
tube, toileted, given range-of-motion exercises, and so forth to preserve physiological integrity. Higher
level needs are of lesser concern.
10. A patient diagnosed with schizophrenia demonstrates little spontaneous movement and has waxy
flexibility. The patients’ activities of daily living are severely compromised. An appropriate outcome
would be that the patient will:
a. demonstrates increased interest in the environment by the end of week 1.
b. performs self-care activities with coaching by the end of day 3.
c. gradually takes the initiative for self-care by the end of week 2.
d. accept tube feeding without objection by day 2. - ANS - ANS: B
Outcomes related to self-care deficit nursing diagnoses should deal with increasing ability to perform
self-care tasks independently, such as feeding, bathing, dressing, and toileting. Performing the tasks
with coaching by nursing staff denotes improvement over the complete inability to perform the tasks.
The incorrect options are not directly related to self-care activities, difficult to measure, and unrelated
to maintenance of nutrition.
11. A nurse observes a catatonic patient standing immobile, facing the wall with one arm extended in a
salute. The patient remains immobile in this position for 15 minutes, moving only when the nurse gently
lowers the arm. What is the name of this phenomenon?
a. Echolalia c. Depersonalization
b. Waxy flexibility
c. Depersonalization
d. Thought withdrawal - ANS - ANS: B
Waxy flexibility is the ability to hold distorted postures for extended periods of time, as though the
patient were molded in wax. Echolalia is a speech pattern. Depersonalization refers to a feeling state.
Thought withdrawal refers to an alteration in thinking.
and 23): 2023/2024 questions and answers, end of
chapter
1. A person has had difficulty keeping a job because of arguing with co-workers and accusing them of
conspiracy. Today the person shouts, they’re all plotting to destroy me. Isn’t that true? Select the nurses
most therapeutic response.
a. Everyone here is trying to help you. No one wants to harm you.
b. Feeling that people want to destroy you must be very frightening.
c. That is not true. People here are trying to help you if you will let them.
d. Staff members are health care professionals who are - ANS - ANS: B
Resist focusing on content; instead, focus on the feelings the patient is expressing. This strategy
prevents arguing about the reality of delusional beliefs. Such arguments increase patient anxiety and the
tenacity with which the patient holds to the delusion. The other options focus on content and provide
opportunity for argument.
2. A newly admitted patient diagnosed with schizophrenia is hyper vigilant and constantly scans the
environment. The patient states, I saw two doctors talking in the hall. They were plotting to kill me. The
nurse may correctly assess this behavior as:
a. echolalia.
b. an idea of reference.
c. a delusion of infidelity.
d. an auditory hallucination. - ANS - ANS: B
Ideas of reference are misinterpretations of the verbalizations or actions of others that give special
personal meanings to these behaviors; for example, when seeing two people talking, the individual
assumes they are talking about him or her. The other terms do not correspond with the scenario.
3. A patient diagnosed with schizophrenia says, my co-workers are out to get me. I also saw two doctors
plotting to kill me. How does this patient perceive the environment?
a. Disorganized
,b. Dangerous
c. Supportive
d. Bizarre - ANS - ANS: B
The patient sees the world as hostile and dangerous. This assessment is important because the nurse
can be more effective by using empathy to respond to the patient. Data are not present to support any
of the other options.
4. When a patient diagnosed with schizophrenia was discharged 6 months ago, haloperidol (Haldol) was
prescribed. The patient now says, I stopped taking those pills. They made me feel like a robot. What are
common side effects the nurse should validate with the patient?
a. Sedation and muscle stiffness
b. Sweating, nausea, and diarrhea
c. Mild fever, sore throat, and skin rash
d. Headache, watery eyes, and runny nose - ANS - ANS: A
Typical antipsychotic drugs often produce sedation and extrapyramidal side effects such as stiffness and
gait disturbance, effects the patient might describe as making him or her feel like a robot. The side
effects mentioned in the other options are usually not associated with typical antipsychotic therapy or
would not have the effect described by the patient.
5. Which hallucination necessitates the nurse to implement safety measures? The patient says,
a. I hear angels playing harps.
b. The voices say everyone is trying to kill me.
c. My dead father tells me I am a good person.
d. The voices talk only at night when I’m trying to sleep. - ANS - ANS: B
The correct response indicates the patient is experiencing paranoia. Paranoia often leads to fearfulness,
and the patient may attempt to strike out at others to protect self. The distracters are comforting
hallucinations or do not indicate paranoia.
6. A patients care plan includes monitoring for auditory hallucinations. Which assessment findings
suggest the patient may be hallucinating?
a. Detachment and overconfidence
b. Darting eyes, tilted head, mumbling to self
,c. Euphoric mood, hyperactivity, distractibility
d. Foot tapping and repeatedly writing the same phrase - ANS - ANS: B
Clues to hallucinations include eyes looking around the room as though to find the speaker, tilting the
head to one side as though listening intently, and grimacing, mumbling, or talking aloud as though
responding conversationally to someone.
7. A health care provider considers which antipsychotic medication to prescribe for a patient diagnosed
with schizophrenia who has auditory hallucinations and poor social function. The patient is also
overweight and hypertensive. Which drug should the nurse advocate?
a. Clozapine (Clozaril)
b. Ziprasidone (Geodon)
c. Olanzapine (Zyprexa)
d. Aripiprazole (Abilify) - ANS - ANS: D
Aripiprazole is a third-generation atypical antipsychotic effective against both positive and negative
symptoms of schizophrenia. It causes little or no weight gain and no increase in glucose, high- or low-
density lipoprotein cholesterol, or triglycerides, making it a reasonable choice for a patient with obesity
or heart disease. Clozapine may produce agranulocytosis, making it a poor choice as a first-line agent.
Ziprasidone may prolong the QT interval, making it a poor choice for a patient with cardiac disease.
Olanzapine fosters weight gain.
8. A patient diagnosed with schizophrenia tells the nurse, I eat skillet. Tend to end. Easter. It blows away.
Get it? Select the nurses’ best response.
a. Nothing you are saying is clear.
b. Your thoughts are very disconnected.
c. Try to organize your thoughts and then tell me again.
d. I am having difficulty understanding what you are saying. - ANS - ANS: D
When a patients’ speech is loosely associated, confused, and disorganized, pretending to understand is
useless. The nurse should tell the patient that he or she is having difficulty understanding what the
patient is saying. If a theme is discernible, ask the patient to talk about the theme. The incorrect options
tend to place blame for the poor communication with the patient. The correct response places the
difficulty with the nurse rather than being accusatory.
9. A patient diagnosed with schizophrenia exhibits little spontaneous movement and demonstrates waxy
flexibility. Which patient needs are of priority importance?
, a. Self-esteem
b. Psychosocial
c. Physiological
d. Self-actualization - ANS - ANS: C
Physiological needs must be met to preserve life. A patient with waxy flexibility must be fed by hand or
tube, toileted, given range-of-motion exercises, and so forth to preserve physiological integrity. Higher
level needs are of lesser concern.
10. A patient diagnosed with schizophrenia demonstrates little spontaneous movement and has waxy
flexibility. The patients’ activities of daily living are severely compromised. An appropriate outcome
would be that the patient will:
a. demonstrates increased interest in the environment by the end of week 1.
b. performs self-care activities with coaching by the end of day 3.
c. gradually takes the initiative for self-care by the end of week 2.
d. accept tube feeding without objection by day 2. - ANS - ANS: B
Outcomes related to self-care deficit nursing diagnoses should deal with increasing ability to perform
self-care tasks independently, such as feeding, bathing, dressing, and toileting. Performing the tasks
with coaching by nursing staff denotes improvement over the complete inability to perform the tasks.
The incorrect options are not directly related to self-care activities, difficult to measure, and unrelated
to maintenance of nutrition.
11. A nurse observes a catatonic patient standing immobile, facing the wall with one arm extended in a
salute. The patient remains immobile in this position for 15 minutes, moving only when the nurse gently
lowers the arm. What is the name of this phenomenon?
a. Echolalia c. Depersonalization
b. Waxy flexibility
c. Depersonalization
d. Thought withdrawal - ANS - ANS: B
Waxy flexibility is the ability to hold distorted postures for extended periods of time, as though the
patient were molded in wax. Echolalia is a speech pattern. Depersonalization refers to a feeling state.
Thought withdrawal refers to an alteration in thinking.
