Psych/Mental Health Exit HESI – Saunders Exam
Questions and Answers| Latest Update 100% Solved |
Guaranteed Success
The mental health nurse is talking to a client who has been diagnosed with posttraumatic stress
disorder. During the conversation, the nurse notes that the client is exhibiting a paranoid stare
and that he begins to pace and fidget. What is the appropriate nursing intervention?
1. Allow the client to pace.
2. Escort the client to a quiet room.
3. Change the conversation to a less threatening subject.
4. Share the observation with the client and help the client to recognize his feelings. 4. Share
the observation with the client and help the client to recognize his feelings.
Rationale:
Sharing observations with the client may help him recognize and acknowledge feelings. Allowing
the client to pace may also allow him to get out of control. Moving to a quiet room or changing
the subject will not help the client to recognize his behaviors and feelings.
The nurse is reviewing the record of a client admitted to the mental health unit. The nurse notes
documentation that the client experiences flashbacks. What diagnosis should the nurse expect
to be documented for this client?
1. Anxiety
2. Agoraphobia
3. Schizophrenia
4. Posttraumatic stress disorder (PTSD) 4. Posttraumatic stress disorder (PTSD)
,Rationale:
The major clinical manifestation associated with PTSD is client experience of flashbacks.
Flashbacks are not specifically associated with anxiety, agoraphobia, or schizophrenia.
The nurse is admitting a client with a diagnosis of posttraumatic stress disorder to the mental
health unit. The client is confused and disoriented. During the assessment, what is the nurse's
primary goal for this client?
1. Explain the unit rules.
2. Orient the client to the unit.
3. Stabilize the client's psychiatric needs.
4. Accept the client and make the client feel safe. 4. Accept the client and make the client
feel safe.
Rationale:
It is important to make a confused client feel safe. Explaining the unit rules and orientation to
the unit are part of any admission process. Stabilizing psychiatric needs is a long-term goal.
The nurse in the mental health unit is having a conversation with a client diagnosed with
posttraumatic stress disorder. The client seems upset and looks anxious. What is the
appropriate nursing statement the nurse should make to the client?
1. "Don't worry so much."
2. "I can see that you are upset."
3. "Everything is going to be all right."
4. "Why are you having so much trouble controlling your anxiety?" 2. "I can see that you are
upset."
,Rationale:
The correct option is the only one that addresses the client's feelings and concerns. Options 1
and 3 provide false reassurance and place the client's feelings on hold. Option 4 is a
nontherapeutic communication technique and will increase the client's anxiety.
A client with depression is scheduled to receive three sessions of electroconvulsive therapy
(ECT). The client asks the nurse about the length of time it will take for improvement in the
condition. The nurse should tell the client he or she will see improvement approximately how
long after the three treatments?
1. 1 week
2. 3 weeks
3. 4 weeks
4. 8 weeks 1. 1 week
Rationale:
Health care providers generally administer ECT treatments three times a week, with an average
series including 8 to 12 treatments. After three sessions of ECT, the client should start to
demonstrate improvement in 1 week. Options 2, 3, and 4 are incorrect.
A client has been diagnosed with major depression. The nurse notes that the client is not eating
adequately and at times refuses to eat. What should the nurse plan to do to meet the client's
nutritional needs?
1. Force foods and fluids.
2. Provide small, frequent meals.
3. Provide snacks and meals as requested.
4. Tell the client that social activities will be restricted unless food intake is increased. 2.
Provide small, frequent meals.
, Rationale:
A depressed client may eat small amounts of food because large amounts may seem
overwhelming. If the client becomes overwhelmed, he or she may respond by withdrawing
further. Providing snacks and meals when the client requests them will not ensure adequate
nutritional intake. Forcing foods and fluids and telling the client that social activities will be
restricted will cause further withdrawal by the client. Telling the client that social activities will
be restricted also is a demeaning action.
The health care provider has prescribed medication therapy for a client with an alcohol abuse
problem to assist in the maintenance of sobriety. The nurse reviews the client's record and
expects to note that which medication has been prescribed?
1. Clonidine (Catapres)
2. Disulfiram (Antabuse)
3. Pyridoxine hydrochloride (vitamin B6)
4. Chlordiazepoxide hydrochloride (Librium) 2. Disulfiram (Antabuse)
Rationale:
Disulfiram is a medication used for alcoholism, and it aids in the maintenance of sobriety.
Clonidine is an antihypertensive medication. Pyridoxine hydrochloride is used in the treatment
of vitamin B6 deficiency. Chlordiazepoxide hydrochloride is an antianxiety medication (a
benzodiazepine) that is used in the management of acute alcohol withdrawal symptoms.
The mental health nurse is caring for a client with a social phobia. The nurse tells the client that
a music therapy session has been scheduled as part of the treatment plan. The client tells the
nurse that she cannot sing and refuses to attend. What is the appropriate nursing response?
1. "You must go. You have no choice."
2. "Why don't you want to attend? What is the real reason?"
Questions and Answers| Latest Update 100% Solved |
Guaranteed Success
The mental health nurse is talking to a client who has been diagnosed with posttraumatic stress
disorder. During the conversation, the nurse notes that the client is exhibiting a paranoid stare
and that he begins to pace and fidget. What is the appropriate nursing intervention?
1. Allow the client to pace.
2. Escort the client to a quiet room.
3. Change the conversation to a less threatening subject.
4. Share the observation with the client and help the client to recognize his feelings. 4. Share
the observation with the client and help the client to recognize his feelings.
Rationale:
Sharing observations with the client may help him recognize and acknowledge feelings. Allowing
the client to pace may also allow him to get out of control. Moving to a quiet room or changing
the subject will not help the client to recognize his behaviors and feelings.
The nurse is reviewing the record of a client admitted to the mental health unit. The nurse notes
documentation that the client experiences flashbacks. What diagnosis should the nurse expect
to be documented for this client?
1. Anxiety
2. Agoraphobia
3. Schizophrenia
4. Posttraumatic stress disorder (PTSD) 4. Posttraumatic stress disorder (PTSD)
,Rationale:
The major clinical manifestation associated with PTSD is client experience of flashbacks.
Flashbacks are not specifically associated with anxiety, agoraphobia, or schizophrenia.
The nurse is admitting a client with a diagnosis of posttraumatic stress disorder to the mental
health unit. The client is confused and disoriented. During the assessment, what is the nurse's
primary goal for this client?
1. Explain the unit rules.
2. Orient the client to the unit.
3. Stabilize the client's psychiatric needs.
4. Accept the client and make the client feel safe. 4. Accept the client and make the client
feel safe.
Rationale:
It is important to make a confused client feel safe. Explaining the unit rules and orientation to
the unit are part of any admission process. Stabilizing psychiatric needs is a long-term goal.
The nurse in the mental health unit is having a conversation with a client diagnosed with
posttraumatic stress disorder. The client seems upset and looks anxious. What is the
appropriate nursing statement the nurse should make to the client?
1. "Don't worry so much."
2. "I can see that you are upset."
3. "Everything is going to be all right."
4. "Why are you having so much trouble controlling your anxiety?" 2. "I can see that you are
upset."
,Rationale:
The correct option is the only one that addresses the client's feelings and concerns. Options 1
and 3 provide false reassurance and place the client's feelings on hold. Option 4 is a
nontherapeutic communication technique and will increase the client's anxiety.
A client with depression is scheduled to receive three sessions of electroconvulsive therapy
(ECT). The client asks the nurse about the length of time it will take for improvement in the
condition. The nurse should tell the client he or she will see improvement approximately how
long after the three treatments?
1. 1 week
2. 3 weeks
3. 4 weeks
4. 8 weeks 1. 1 week
Rationale:
Health care providers generally administer ECT treatments three times a week, with an average
series including 8 to 12 treatments. After three sessions of ECT, the client should start to
demonstrate improvement in 1 week. Options 2, 3, and 4 are incorrect.
A client has been diagnosed with major depression. The nurse notes that the client is not eating
adequately and at times refuses to eat. What should the nurse plan to do to meet the client's
nutritional needs?
1. Force foods and fluids.
2. Provide small, frequent meals.
3. Provide snacks and meals as requested.
4. Tell the client that social activities will be restricted unless food intake is increased. 2.
Provide small, frequent meals.
, Rationale:
A depressed client may eat small amounts of food because large amounts may seem
overwhelming. If the client becomes overwhelmed, he or she may respond by withdrawing
further. Providing snacks and meals when the client requests them will not ensure adequate
nutritional intake. Forcing foods and fluids and telling the client that social activities will be
restricted will cause further withdrawal by the client. Telling the client that social activities will
be restricted also is a demeaning action.
The health care provider has prescribed medication therapy for a client with an alcohol abuse
problem to assist in the maintenance of sobriety. The nurse reviews the client's record and
expects to note that which medication has been prescribed?
1. Clonidine (Catapres)
2. Disulfiram (Antabuse)
3. Pyridoxine hydrochloride (vitamin B6)
4. Chlordiazepoxide hydrochloride (Librium) 2. Disulfiram (Antabuse)
Rationale:
Disulfiram is a medication used for alcoholism, and it aids in the maintenance of sobriety.
Clonidine is an antihypertensive medication. Pyridoxine hydrochloride is used in the treatment
of vitamin B6 deficiency. Chlordiazepoxide hydrochloride is an antianxiety medication (a
benzodiazepine) that is used in the management of acute alcohol withdrawal symptoms.
The mental health nurse is caring for a client with a social phobia. The nurse tells the client that
a music therapy session has been scheduled as part of the treatment plan. The client tells the
nurse that she cannot sing and refuses to attend. What is the appropriate nursing response?
1. "You must go. You have no choice."
2. "Why don't you want to attend? What is the real reason?"
