TEST BANK FOR HESI MENTAL HEALTH
RN V1-V3|| 100% VERIFIED|A+ RATED.
A patient with depression remains in bed most of the day, and declines
activities. Which nursing problem has the greatest priorityfor this patient?
• Loss of interest in diversional activity.
• Social isolation.
• Refusal to address nutritional needs.
• Low self-esteem.
The RN is preparing medications for a patient with bipolar disorder and notices
that the patient discontinued antipsychotic medication for several days. Which
medication should also be discontinued?
• Lithium. (Lithotabs)
• Benzotropine (Cogentin).
• Alprazolam (Xanax).
• Magnesium (Milk of Magnesia).
A female patient requests that her husband be allowed to stay in theroom
during the admission assessment. When interviewing the patient, the RN
notes a discrepancy between the patient’s verbal and nonverbal
communication.
What action does the RN take?
• Pay close attention and document the nonverbal messages.
• Ask the patient’s husband to interpret the discrepancy.
• Ignore the nonverbal behavior and focus on the patient’sverbal
messages.
• Integrate the verbal and nonverbal messages and interpretthem as
one.
A male patient approaches the RN with an angry expression on his face and
raises his voice, saying “My roommate is the most selfish, self-centered, angry
person I have ever met. If he loses his temperone more time with me, I am
going to punch him out!” The RN recognizes that the patient is using which
defense mechanism?
A.
Deni
al.B.
, Projection
.
C. Rationalization.
D. Splitting.
A male patient with bipolar disorder who began taking lithium carbonate five
days ago is complaining of excessive thirst, and theRN finds him attempting to
drink water from the bathroom sink faucet. Which intervention should the RN
implement?
• Report the patient’s serum lithium level to the HCP.
• Encourage the patient to suck on hard candy to relieve thesymptoms.
• No action is needed since polydipsia is a common side effect.
• Tell the patient that drinking from the faucet is not allowed.
The RN is teaching a patient about the initiation of the prescribed abstinence
therapy using disulfiram (Antabuse). What informationshould the patient
acknowledge understanding?
• Completely abstain from heroin or cocaine use.
• Remain alcohol free for 12 hours prior to the first dose.
• Attend monthly meetings of alcoholics anonymous.
• Admit to others that he is a substance user.
A male patient with schizophrenia is admitted to the mental health unit after
abruptly stopping his prescription for ziprasidone (Geodon) one month ago.
Which question is most important for theRN to ask the patient?
• Have you lost interest in the things that you used to enjoy?
• Is your ability to think or concentrate decreased?
• How many continuous hours do you sleep atnight? D.
Do you hear sounds or voices that others do not hear?
During an annual physical by the occupational RN working in a corporate
clinic, a male employee tells the RN that is high-stress jobis causing trouble in
his personal life. He further explains that he often gets so angry while driving
to and from work that he has considered “getting even” with other drivers.
How should the RN respond?
• “Anger is contagious and could result in major confrontation.”
• “Try not to let your anger cause you to act impulsively.”
• “Expressing your anger to a stranger could result inan unsafe
situation.”
• “It sounds as if there are many situations that make you feelangry.”
,A patient who has agoraphobia (a fear of crowds) is beginning desensitization
with the therapist, and the RN is reinforcing the process. Which intervention has
the highest priority for this patient’s plan of care?
• Encourage substitution of positive thoughts and negative ones.
• Establish trust by providing a calm, safe environment.
• Progressively expose the patient to larger crowds.
• Encourage deep breathing when anxiety escalates in a crowd.
Which nursing actions are likely to help promote the self-esteem of amale patient
with modern depression?
• Ask the patient what his long term goals are.
• Discuss the challenges of his medical condition.
• Include the patient in determining treatment
protocol. D. Encourage the patient to engage in
recreational therapy.
E. Provide opportunities for the patient to discuss his concerns.
A male patient is admitted to the psychiatric unit for recurrent negative
symptoms of chronic schizophrenia and medication adjustment of Risperidone
(Risperdal). When the patient walks to thenurse’s station in a laterally contracted
position, he states that something has made his body contort into a monster.
What action should the RN take?
• Medicate the patient with the prescribed antipsychotic
thioridazine (Mellaril).
• Offer the patient a prescribed physical therapy hot pack for
muscle spasms.
• Direct patient to occupational therapy to distract him from
somatic complaints.
• Administer the prescribed anticholinergic benztropine
(Cogentin) for dystonia.
A mental health worker is caring for a patient with escalating aggressive
behavior. Which action by the MHW warrant immediateintervention by the
RN?
• Is attempting to physically restrain the patient.
• Tells the patient to go to the quiet area of the unit.
• Is using a loid voice to talk to the patient.
• Remains at a distance of 4 feet from the patient.
, A patient on the mental health unit is becoming more agitated, shouting at the
staff, and pacing in the hallway. When the PRN medication is offered, the
patient refuses the medication and defiantlysits on the floor in the middle of
the unit hallway. What nursing intervention should the RN implement first?
• Transport of the patient to the seclusion room.
• Quietly approach the patient with additional staff members.
C. Take other patients in the area to the patientlounge.
D. Administer medication to chemically restrain the patient.
A patient is admitted to the mental health unit and reports taking extra antianxiety
medication because, “I’m so stressed out. I just want to go to sleep.” The RN
should plan one-on-one observation of the patientbased on which statement?
• “What should I do? Nothing seems to help.”
• “I have been so tired lately and needed to sleep.”
• “I really think that I don’t need to be here.”
• “I don’t want to walk. Nothing matters anymore.”
A male hospital employee is pushed out the way by a female employee because
of an oncoming gurney. The pushed employee becomes very angry and swings
at the female employee. Both employees are referred for counseling with the
staff psychiatric RN. Which factor in the pushed employee’s history is most
related to thereaction that occurred?
• Is worried about losing his job to a woman.
• Tortured animals as a child.
• Was physically abused by his mother.
• Hates to be touched by anyone.
The RN documents the mental status of a female patient who has been
hospitalized for several days by court order. The patient states, “Idon’t need to
be here” and tells the RN that she believes the television talks to her. The RN
should document these assessment findings in which section of the mental
status exam/
A. Level of
concentration. B. Insight
and judgement.
C. Remote memory.
D. Mood and affect.
A patient is admitted to the mental health unit reports shortness of breath and
dizziness. The patient tells the RN, “I feel like I’m going to die”. Which nursing
problem should the RN include in this patient’s planof care?
RN V1-V3|| 100% VERIFIED|A+ RATED.
A patient with depression remains in bed most of the day, and declines
activities. Which nursing problem has the greatest priorityfor this patient?
• Loss of interest in diversional activity.
• Social isolation.
• Refusal to address nutritional needs.
• Low self-esteem.
The RN is preparing medications for a patient with bipolar disorder and notices
that the patient discontinued antipsychotic medication for several days. Which
medication should also be discontinued?
• Lithium. (Lithotabs)
• Benzotropine (Cogentin).
• Alprazolam (Xanax).
• Magnesium (Milk of Magnesia).
A female patient requests that her husband be allowed to stay in theroom
during the admission assessment. When interviewing the patient, the RN
notes a discrepancy between the patient’s verbal and nonverbal
communication.
What action does the RN take?
• Pay close attention and document the nonverbal messages.
• Ask the patient’s husband to interpret the discrepancy.
• Ignore the nonverbal behavior and focus on the patient’sverbal
messages.
• Integrate the verbal and nonverbal messages and interpretthem as
one.
A male patient approaches the RN with an angry expression on his face and
raises his voice, saying “My roommate is the most selfish, self-centered, angry
person I have ever met. If he loses his temperone more time with me, I am
going to punch him out!” The RN recognizes that the patient is using which
defense mechanism?
A.
Deni
al.B.
, Projection
.
C. Rationalization.
D. Splitting.
A male patient with bipolar disorder who began taking lithium carbonate five
days ago is complaining of excessive thirst, and theRN finds him attempting to
drink water from the bathroom sink faucet. Which intervention should the RN
implement?
• Report the patient’s serum lithium level to the HCP.
• Encourage the patient to suck on hard candy to relieve thesymptoms.
• No action is needed since polydipsia is a common side effect.
• Tell the patient that drinking from the faucet is not allowed.
The RN is teaching a patient about the initiation of the prescribed abstinence
therapy using disulfiram (Antabuse). What informationshould the patient
acknowledge understanding?
• Completely abstain from heroin or cocaine use.
• Remain alcohol free for 12 hours prior to the first dose.
• Attend monthly meetings of alcoholics anonymous.
• Admit to others that he is a substance user.
A male patient with schizophrenia is admitted to the mental health unit after
abruptly stopping his prescription for ziprasidone (Geodon) one month ago.
Which question is most important for theRN to ask the patient?
• Have you lost interest in the things that you used to enjoy?
• Is your ability to think or concentrate decreased?
• How many continuous hours do you sleep atnight? D.
Do you hear sounds or voices that others do not hear?
During an annual physical by the occupational RN working in a corporate
clinic, a male employee tells the RN that is high-stress jobis causing trouble in
his personal life. He further explains that he often gets so angry while driving
to and from work that he has considered “getting even” with other drivers.
How should the RN respond?
• “Anger is contagious and could result in major confrontation.”
• “Try not to let your anger cause you to act impulsively.”
• “Expressing your anger to a stranger could result inan unsafe
situation.”
• “It sounds as if there are many situations that make you feelangry.”
,A patient who has agoraphobia (a fear of crowds) is beginning desensitization
with the therapist, and the RN is reinforcing the process. Which intervention has
the highest priority for this patient’s plan of care?
• Encourage substitution of positive thoughts and negative ones.
• Establish trust by providing a calm, safe environment.
• Progressively expose the patient to larger crowds.
• Encourage deep breathing when anxiety escalates in a crowd.
Which nursing actions are likely to help promote the self-esteem of amale patient
with modern depression?
• Ask the patient what his long term goals are.
• Discuss the challenges of his medical condition.
• Include the patient in determining treatment
protocol. D. Encourage the patient to engage in
recreational therapy.
E. Provide opportunities for the patient to discuss his concerns.
A male patient is admitted to the psychiatric unit for recurrent negative
symptoms of chronic schizophrenia and medication adjustment of Risperidone
(Risperdal). When the patient walks to thenurse’s station in a laterally contracted
position, he states that something has made his body contort into a monster.
What action should the RN take?
• Medicate the patient with the prescribed antipsychotic
thioridazine (Mellaril).
• Offer the patient a prescribed physical therapy hot pack for
muscle spasms.
• Direct patient to occupational therapy to distract him from
somatic complaints.
• Administer the prescribed anticholinergic benztropine
(Cogentin) for dystonia.
A mental health worker is caring for a patient with escalating aggressive
behavior. Which action by the MHW warrant immediateintervention by the
RN?
• Is attempting to physically restrain the patient.
• Tells the patient to go to the quiet area of the unit.
• Is using a loid voice to talk to the patient.
• Remains at a distance of 4 feet from the patient.
, A patient on the mental health unit is becoming more agitated, shouting at the
staff, and pacing in the hallway. When the PRN medication is offered, the
patient refuses the medication and defiantlysits on the floor in the middle of
the unit hallway. What nursing intervention should the RN implement first?
• Transport of the patient to the seclusion room.
• Quietly approach the patient with additional staff members.
C. Take other patients in the area to the patientlounge.
D. Administer medication to chemically restrain the patient.
A patient is admitted to the mental health unit and reports taking extra antianxiety
medication because, “I’m so stressed out. I just want to go to sleep.” The RN
should plan one-on-one observation of the patientbased on which statement?
• “What should I do? Nothing seems to help.”
• “I have been so tired lately and needed to sleep.”
• “I really think that I don’t need to be here.”
• “I don’t want to walk. Nothing matters anymore.”
A male hospital employee is pushed out the way by a female employee because
of an oncoming gurney. The pushed employee becomes very angry and swings
at the female employee. Both employees are referred for counseling with the
staff psychiatric RN. Which factor in the pushed employee’s history is most
related to thereaction that occurred?
• Is worried about losing his job to a woman.
• Tortured animals as a child.
• Was physically abused by his mother.
• Hates to be touched by anyone.
The RN documents the mental status of a female patient who has been
hospitalized for several days by court order. The patient states, “Idon’t need to
be here” and tells the RN that she believes the television talks to her. The RN
should document these assessment findings in which section of the mental
status exam/
A. Level of
concentration. B. Insight
and judgement.
C. Remote memory.
D. Mood and affect.
A patient is admitted to the mental health unit reports shortness of breath and
dizziness. The patient tells the RN, “I feel like I’m going to die”. Which nursing
problem should the RN include in this patient’s planof care?
