MENTAL HEALTH/PSYCH HESI
RATIONALE REVIEW EXAM
QUESTIONS WITH CORRECT
ANSWERS
A 25-year-old client has suffered extensive burns and is crying during dressing
change treatment. The client tells the nurse, "Please let me die. Why are you all
torturing me like this? I just want to die." Which response by the nurse is best?
A."We aren't torturing you. These treatments are necessary to prevent a terrible
infection."
B."I know these treatments must seem like torture to you, but we want to help you
recover."
C."You have so much to live for, and all of your family members want you to live."
D."Would you like me to call the chaplain so that you can discuss your feelings
privately?" - Answer-ANS: B
(B) offers an empathetic response without sounding patronizing. (A) is not
empathetic and is actually somewhat argumentative. The client is not asking for
information as much as pleading for understanding. (C) appears as scolding and
places blame on the client for wanting to die and possibly hurting the client's family
members as a result. (D) might be appropriate if the nurse simply asks the client if a
chaplain's visit is desired, but the nurse is dismissing the client's needs by not
addressing them at the moment.
The nurse admits a client with depression to the mental health unit. The client
reports difficulty concentrating, has lost 10 pounds in 2 weeks, and is sleeping 12
hours a day. Which outcome is most important for the client to meet by discharge?
A.Tries to interact with a few peers and staff
B.Reports feeling better and less depressed
C.Sits attentively with peers in group therapy
D.Easily awakens for morning medications - Answer-ANS: B
The client is experiencing symptoms of depression, and the outcome by discharge
for this client would be that the client reports feeling better and less depressed (B).
The client may interact with peers and staff (A) and sit attentively in groups (C)
without any improvement in depression. Difficulty awakening is usually caused by
the medication regimen for depression, so awakening (D) is not an indication of
improvement.
A client mumbles out loud whether anyone is talking to her or not and the client also
mumbles in group when others are talking. The nurse determines that the client is
experiencing hallucinations. Which intervention should the nurse implement?
A.Respond to the client's feelings rather than the illogical thoughts
,B.Identify beliefs and thoughts about what the client is experiencing.
C.Provide the client with hope that the voices will eventually go away.
D.Ask the client how she has previously managed the voices. - Answer-ANS: D
The nurse should promote symptom management and determine how the client
previously managed the voices (D). (A and B) are interventions that are useful with
clients who are experiencing delusions. (C) is important, but the most important
intervention is to promote symptom management.
A client in an acute care facility has been taking antipsychotic medications for the
past 3 days with a decrease in psychotic behaviors and no adverse reactions. On the
fourth day, the client experiences an increase in blood pressure and temperature
and demonstrates muscular rigidity. Which action should the nurse initiate?
A.Place the client on seizure precautions and monitor frequently.
B.Take the client's vital signs and notify the health care provider immediately.
C.Describe the symptoms to the charge nurse and document them in the client's
record.
D.No action is required at this time because these are known side effects of her
medications. - Answer-ANS: B
This is an emergency situation, and the client requires immediate management in a
critical care setting (B). These symptoms are descriptive of neuroleptic malignant
syndrome (NMS), an extremely serious and life-threatening reaction to neuroleptic
drugs. The major symptoms of this syndrome are fever, rigidity, autonomic instability,
and encephalopathy. Respiratory failure, cardiovascular collapse, arrhythmias,
and/or renal failure can result in death. (A) is not indicated in this situation. (C) does
not consider the seriousness of the situation. (D) is an incorrect statement.
On admission, a depressed client tells the nurse, "I can't eat because my tongue is
rubber." Which is the best action for the nurse to implement?
A.Provide packaged foods for the client to eat.
B.Begin the client on total parenteral nutritional (TPN) therapy.
C.Provide a well-balanced liquid diet for the client.
D.No action is necessary because the client will eat when hungry. - Answer-ANS: C
The nurse should strive to provide a safe environment (adequate nutrition is part of a
safe environment) and should not argue with the client's delusions. (C) is the least
invasive while providing nutrition that does not argue with the client's delusion. (A) is
given to those with paranoid delusions. (B) is invasive and would be used as a last
resort. (C) should be tried first. This client's delusion could be life threatening and
should not be ignored (D).
Which topics should the nurse include in an education program for clients with
schizophrenia and their families? (Select all that apply.)
A.Importance of adherence to medication regimen
B.Current treatment measures for substance abuse
C.Signs and symptoms of an exacerbation
, D.Prevention of criminal activity
E.Behavior modification for aggression
F.Chronic grief associated with long-term illness - Answer-ANS: A, C, F
Medication adherence is an important component of successful rehabilitation (A).
Clients and their families also need to know the signs and symptoms of an
exacerbation or relapse of the disease (C), which is frequently associated with poor
medication compliance. Acknowledging the chronic sorrow associated with severe
and persistent mental illness (F) helps individuals negotiate the grieving process. (B,
D, and E) are not universal problems associated with schizophrenia.
On admission, a highly anxious client is described as delusional. Delusions are most
likely to occur with which disorder?
A.Dissociative disorders
B.Personality disorders
C.Anxiety disorders
D.Psychotic disorders - Answer-ANS: D
Delusions are false beliefs characteristic of psychosis (D). Delusions are generally
not characteristic of (A, B, and C).
A 35-year-old client admitted to the psychiatric unit of an acute care hospital tells the
nurse that someone is trying to poison her. The client's delusions are most likely
related to which factor?
A.Authority issues in childhood
B.Anger about being hospitalized
C.Low self-esteem
D.Phobia of food - Answer-ANS: C
Delusional clients have difficulty with trust and have low self-esteem (C). Nursing
care should be directed at building trust and promoting positive self-esteem.
Activities with limited concentration and no competition should be encouraged to
build self-esteem. (A, B, and D) are not specifically related to the development of
delusions.
Clients are preparing to leave the mental health unit for an outdoor smoke break. A
client on constant observation cannot leave and becomes agitated and demands to
smoke a cigarette. Which action should the nurse take first?
A.Remind the client to wear the nicotine (NicoDerm) patch.
B.Determine if the client still needs constant observation.
C.Encourage the client to attend the smoking cessation group.
D.Explain that clients on constant observation cannot smoke. - Answer-ANS: B
The nurse should continually reassess the need for constant observation (B) so that
the client can have unit privileges such as outdoor breaks. (A and C) do not meet the
client's need and desire to smoke. (D) will cause more agitation.
RATIONALE REVIEW EXAM
QUESTIONS WITH CORRECT
ANSWERS
A 25-year-old client has suffered extensive burns and is crying during dressing
change treatment. The client tells the nurse, "Please let me die. Why are you all
torturing me like this? I just want to die." Which response by the nurse is best?
A."We aren't torturing you. These treatments are necessary to prevent a terrible
infection."
B."I know these treatments must seem like torture to you, but we want to help you
recover."
C."You have so much to live for, and all of your family members want you to live."
D."Would you like me to call the chaplain so that you can discuss your feelings
privately?" - Answer-ANS: B
(B) offers an empathetic response without sounding patronizing. (A) is not
empathetic and is actually somewhat argumentative. The client is not asking for
information as much as pleading for understanding. (C) appears as scolding and
places blame on the client for wanting to die and possibly hurting the client's family
members as a result. (D) might be appropriate if the nurse simply asks the client if a
chaplain's visit is desired, but the nurse is dismissing the client's needs by not
addressing them at the moment.
The nurse admits a client with depression to the mental health unit. The client
reports difficulty concentrating, has lost 10 pounds in 2 weeks, and is sleeping 12
hours a day. Which outcome is most important for the client to meet by discharge?
A.Tries to interact with a few peers and staff
B.Reports feeling better and less depressed
C.Sits attentively with peers in group therapy
D.Easily awakens for morning medications - Answer-ANS: B
The client is experiencing symptoms of depression, and the outcome by discharge
for this client would be that the client reports feeling better and less depressed (B).
The client may interact with peers and staff (A) and sit attentively in groups (C)
without any improvement in depression. Difficulty awakening is usually caused by
the medication regimen for depression, so awakening (D) is not an indication of
improvement.
A client mumbles out loud whether anyone is talking to her or not and the client also
mumbles in group when others are talking. The nurse determines that the client is
experiencing hallucinations. Which intervention should the nurse implement?
A.Respond to the client's feelings rather than the illogical thoughts
,B.Identify beliefs and thoughts about what the client is experiencing.
C.Provide the client with hope that the voices will eventually go away.
D.Ask the client how she has previously managed the voices. - Answer-ANS: D
The nurse should promote symptom management and determine how the client
previously managed the voices (D). (A and B) are interventions that are useful with
clients who are experiencing delusions. (C) is important, but the most important
intervention is to promote symptom management.
A client in an acute care facility has been taking antipsychotic medications for the
past 3 days with a decrease in psychotic behaviors and no adverse reactions. On the
fourth day, the client experiences an increase in blood pressure and temperature
and demonstrates muscular rigidity. Which action should the nurse initiate?
A.Place the client on seizure precautions and monitor frequently.
B.Take the client's vital signs and notify the health care provider immediately.
C.Describe the symptoms to the charge nurse and document them in the client's
record.
D.No action is required at this time because these are known side effects of her
medications. - Answer-ANS: B
This is an emergency situation, and the client requires immediate management in a
critical care setting (B). These symptoms are descriptive of neuroleptic malignant
syndrome (NMS), an extremely serious and life-threatening reaction to neuroleptic
drugs. The major symptoms of this syndrome are fever, rigidity, autonomic instability,
and encephalopathy. Respiratory failure, cardiovascular collapse, arrhythmias,
and/or renal failure can result in death. (A) is not indicated in this situation. (C) does
not consider the seriousness of the situation. (D) is an incorrect statement.
On admission, a depressed client tells the nurse, "I can't eat because my tongue is
rubber." Which is the best action for the nurse to implement?
A.Provide packaged foods for the client to eat.
B.Begin the client on total parenteral nutritional (TPN) therapy.
C.Provide a well-balanced liquid diet for the client.
D.No action is necessary because the client will eat when hungry. - Answer-ANS: C
The nurse should strive to provide a safe environment (adequate nutrition is part of a
safe environment) and should not argue with the client's delusions. (C) is the least
invasive while providing nutrition that does not argue with the client's delusion. (A) is
given to those with paranoid delusions. (B) is invasive and would be used as a last
resort. (C) should be tried first. This client's delusion could be life threatening and
should not be ignored (D).
Which topics should the nurse include in an education program for clients with
schizophrenia and their families? (Select all that apply.)
A.Importance of adherence to medication regimen
B.Current treatment measures for substance abuse
C.Signs and symptoms of an exacerbation
, D.Prevention of criminal activity
E.Behavior modification for aggression
F.Chronic grief associated with long-term illness - Answer-ANS: A, C, F
Medication adherence is an important component of successful rehabilitation (A).
Clients and their families also need to know the signs and symptoms of an
exacerbation or relapse of the disease (C), which is frequently associated with poor
medication compliance. Acknowledging the chronic sorrow associated with severe
and persistent mental illness (F) helps individuals negotiate the grieving process. (B,
D, and E) are not universal problems associated with schizophrenia.
On admission, a highly anxious client is described as delusional. Delusions are most
likely to occur with which disorder?
A.Dissociative disorders
B.Personality disorders
C.Anxiety disorders
D.Psychotic disorders - Answer-ANS: D
Delusions are false beliefs characteristic of psychosis (D). Delusions are generally
not characteristic of (A, B, and C).
A 35-year-old client admitted to the psychiatric unit of an acute care hospital tells the
nurse that someone is trying to poison her. The client's delusions are most likely
related to which factor?
A.Authority issues in childhood
B.Anger about being hospitalized
C.Low self-esteem
D.Phobia of food - Answer-ANS: C
Delusional clients have difficulty with trust and have low self-esteem (C). Nursing
care should be directed at building trust and promoting positive self-esteem.
Activities with limited concentration and no competition should be encouraged to
build self-esteem. (A, B, and D) are not specifically related to the development of
delusions.
Clients are preparing to leave the mental health unit for an outdoor smoke break. A
client on constant observation cannot leave and becomes agitated and demands to
smoke a cigarette. Which action should the nurse take first?
A.Remind the client to wear the nicotine (NicoDerm) patch.
B.Determine if the client still needs constant observation.
C.Encourage the client to attend the smoking cessation group.
D.Explain that clients on constant observation cannot smoke. - Answer-ANS: B
The nurse should continually reassess the need for constant observation (B) so that
the client can have unit privileges such as outdoor breaks. (A and C) do not meet the
client's need and desire to smoke. (D) will cause more agitation.
