HESI RN MENTAL HEALTH EXAM QUESTIONS AND ANSWERS LATEST UPDATE (1500 Q&A)

A nurse in a mental health clinic is planning care for a client who has a new prescription for olanzapine. Which of the following interventions should the nurse identify as the priority? A) Advise the client to take frequent sips of water. B) Instruct the client to avoid driving during initial therapy. C) Consult a dietitian for a calorie-controlled diet plan. D) Recommend that the client exercise regularly. Answer: B - The greatest risk to this client is injury resulting from drowsiness or dizziness. Therefore, the nurse's priority intervention is to instruct the client to avoid activities that require mental alertness during initial therapy. A charge nurse enters a client's room and observes an assistive personnel (AP) slapping an older client. After moving the client to safety, which of the following actions is the charge nurse's priority? A) Complete an incident report. B) Determine if the client has been physically harmed. C) Provide emotional support to the client. D) Discipline the AP. Answer: B - The greatest risk to this client is injury. Therefore, the priority intervention the charge nurse should take is to determine if the client has injuries that need attention. A nurse is assessing a client who has borderline personality disorder. Which of the following findings should the nurse expect? A) Emotional lability B) Self-sacrificing C) Suspicious of others D) Grandiosity Answer: A - Emotional lability is the rapid transition from one emotion to another and is a primary feature of borderline personality disorder. Clients who have borderline personality disorder react to situations with emotional responses that are out of proportion to the circumstances. A nurse is preparing to administer chlorpromazine 0.55 mg/kg PO to an adolescent who weighs 110 lb. Available is chloropromazine syrup 10 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies.. Do not use a trailing zero.) Answer: 14 mL A nurse is reviewing the chart of a client who has dissociative amnesia. Which of the following findings should the nurse expect? A) The client was seriously injured while under the influence of alcohol. B) The client has a history of panic attacks. C) The client chose to drop out of college a few months ago. D) The client works a stressful job at an international bank. Answer: A - Traumatic events that causes severe stress is a trigger for dissociative amnesia. A nurse is teaching a newly licensed nurse about nursing care plans for clients who have depressive disorders. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A) "I will use the same plan of care and interventions for each client who has depression." B) "Each individual nurse will develop a separate plan of care when managing clients who have depression." C) "I will update the plan of care as a client's manifestations of depression change." D) "An assistive personnel can use the plan of care for client teaching." Answer: C - The nurse should update the plan of care as a client's status and needs change. A nurse is caring for a client who have birth to a stillborn baby. Which of the following statements should the nurse make? A) "You probably want to hold your baby." B) "I'll stay with you just in case you want to talk." C) "I know how you must be feeling." D) "It hurts now, but things will be better soon." Answer: B - This response indicates the nurse's interest in the client and a desire to understand the client's feelings. A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take? A) Orient the client to person, place and time. B) Assist the client with deep-breathing exercises. C) Calm the client by using therapeutic touch. D) Have the client sit alone in a quiet room. Answer: B - Relaxation techniques, such as deep, abdominal breathing exercises, help defuse manifestations of anxiety. A nurse is teaching a family member and a client who has a new diagnosis of Alzheimer’s disease and is to start taking donepezil. Which of the following statements should the nurse include in the teaching? A) "Take this medication in the evening at bedtime." B) "Expect this medication reverse the effects of Alzheimer's disease." C) "If you miss a dose double the next dose." D) "You can crush this medication in applesauce." Answer: A - The client should take this medication in the evening at bedtime for optimal effectiveness. A nurse is planning care for a preschool-age child who has ADHD. Which of the following interventions should the nurse identify as the priority? A) Decrease distractions during meal times. B) Provide positive feedback when the child completes a task. C) Clearly identify consequences for unacceptable behavior. D) Remove unnecessary equipment from the child's surroundings. Answer: D - The greatest risk to the child who has ADHD is injury from impulsive behavior and the decreased ability to perceive self-harm. Therefore, the priority intervention is to remove unnecessary equipment from the child's surroundings. A nurse on a medical-surgical unit is assessing a client who sustained injuries 12 hours ago following a motor-vehicle crash. The client's admission blood alcohol level was 325 mg/dL. Which of the following findings should indicate to the nurse that the client is experiencing alcohol withdrawal? A) Somnolence B) Blood pressure 154/96 mm Hg C) Pinpoint pupils D) Blood glucose 210 mg/dL Answer: B - Physical manifestations of alcohol withdrawal occur in addition to psychological effects. A client who is experiencing alcohol withdrawal is expected to have hypertension, tachycardia, and fever greater than 101 degrees F. It will be important for the nurse to rule out infection in the client who has a fever. A nurse is admitting a client who has major depressive disorder and a new prescription for tranylcypromine. Which of the following over-the-counter medications that the client reports taking should alert the nurse to a potential adverse reaction? A) Lansoprazole B) Naproxen C) Magnesium hydroxide D) Phenylephrine Answer: D - Clients who are taking tanycypromine, an MAOI antidepressant, should not take phenylephrine and other over-the-counter medications for sinus congestion colds, or allergies due to their actions on the sympathetic nervous system, which can result in severe hypertension. A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as a negative symptom of this disorder? A) Delusions B)Neologis ms C) Anhedonia D) Echopraxia Answer: C - Negative symptoms of schizophrenia affect a person's ability to interact with others and are less dominant than positive symptoms. These symptoms develop over time. Examples of negative symptoms include flat affect, anergia (lack of energy), anhedonia (inability to enjoy otherwise pleasurable activities), and thought blocking.