Mental Health (PSYCH) HESI - PRACTICE
LATEST SOLUTION (ANSWERED)
The nurse is discussing the grieving process with the client. Which stages are
included in Kubler-Ross' stages of grief? Rank in the correct order.
1. Acceptance
2. Bargaining
3. Denial
4. Anger
5. Depression
Answer:
3. Denial
4. Anger
2. Bargaining
5. Depression
1. Acceptance
Which situation requires priority intervention on an inpatient psychiatric unit?
1. A client is threatening to throw the television at another client.
2. A male client wants to use the phone to call his spouse.
3. A client sitting in a chair is delusional and hallucinating
4. A client has refused to eat anything for the last 2 days.
Answer:
1. A client is threatening to throw the television at another client.
The client diagnosed with bipolar disorder and who is prescribed lithium, an anti
mania medication, is admitted to the psychiatric unit in an acute manic state.
Which intervention should the nurse implement first?
1. Have the laboratory draw a STAT serum lithium level.
2. Evaluate what behavior prompted the psychiatric admission.
3. Assess and treat the client's physiological needs.
4. Administer STAT dose of lithium to the client.
Answer:
3. Assess and treat the client's physiological needs.
The psychiatric unit staff is upset about the new female charge nurse who just
sits in her office all day. One of the staff members informs the clinical manager
indicates a laissez-faire leadership style?
1. "I will schedule a meeting to discuss the concerns of the charge nurse."
2. "I hired the new charge nurse and she is doing what I told her to do."
3. "You and the staff really should take care of this situation on your own."
4. "I will talk to the charge nurse about your concerns and get back to you."
Answer:
3. "You and the staff really should take care of this situation on your own."
(laissez-faire attitude is an "everybody is driving their own train" attitude, you guys take
care of it)(option 1. is democratic. 2. is an autocratic style. authoritarian approach. 4. is
taking charge of the situation.)
,The mental health worker reports that one of the nurses threatened to force-fed
the male client diagnosed with schizophrenia if the client did not eat the meal on
the lunch tray. Which action should the charge nurse take first?
1. Tell the MHW that this intervention is part of the client's care plan.
2. Request the nurse to come to the office and discuss the MHW allegation.
3. Ask the client what happened between him and the nurse during lunch.
4. Ask the MHW to write down the situation to submit to the head nurse.
Answer:
2. Request the nurse to come to the office and discuss the MHW allegation.
(never choose an answer like 4. where it suggests you "pass it up" so that you don't
have to deal with the problem. it will be wrong)
The client diagnosed with paranoid schizophrenia is imminently aggressive and
is dangerous to himself, the other clients, and the psychiatric staff members. The
client is placed in a seclusion room. Which interventions should the psychiatric
nurse implement? Select all that apply.
1. Assess the client every 2 hours for side effects of medication.
2. Tell the client what behavior will prompt the release from seclusion.
3. Do not notify the client's family of the initiation of seclusion.
4. Explain that the client will be in seclusion room for 24 hours.
5. Instruct the MHW to check the client every 10-15 minutes.
Answer:
1. Assess the client every 2 hours for side effects of the medication., 2. Tell the client
what behavior will prompt the release from seclusion., 5. Instruct the MHW to check the
client every 10-15 minutes.
The psychiatric nurse overhears a MHW arguing with a client diagnosed with
paranoid schizophrenia. Which action should the nurse implement?
1. Ask the MHW to go to the nurse's station.
2. Tell the MHW to quit arguing with the client.
3. Notify the clinical manager of the psychiatric unit.
4. Report the behavior to the client abuse committee.
Answer:
1. Ask the MHW to go to the nurse's station. (first thing you are going to do is assess
situation with the MHW.)
The psychiatric nurse has taken 15 minutes extra for the lunch break two times in
the last week. Which action should the female clinical manager implement?
1. Take no action and continue to watch the nurse's behavior.
2. Document the behavior in writing and place in the nurse's file.
3. Tell the nurse to check in and out with her when taking lunch.
4. Talk to the nurse informally about taking 45 minutes for lunch.
Answer:
4. Talk to the nurse informally about taking 45 minutes for lunch. (Assess)
The client diagnosed with Alzheimer's disease is on a special unit for clients with
cognitive disorders. Which assessment data would warrant immediate
intervention by the psychiatric nurse?
1. The client does not know his or her name, date, or place.
2. The client is unable to dress himself or herself without assistance.
, 3. The client is difficult to arouse from sleep.
4. The client needs assistance when eating a meal.
Answer:
3. The client is difficult to arouse from sleep.
The mother of a client recently diagnosed with schizophrenia says to the nurse, "I
was afraid of my son. Will he be alright?" Which response by the psychiatric
nurse supports the ethical principal of veracity?
1. "I can see your fear; you are concerned your son will not be alright."
2. "If your son takes medication, the symptoms can be controlled."
3. "Why were you afraid of your son? Did you think he would hurt you?"
4. "Schizophrenia is a mental ill ness and your son will not be alright."
Answer:
2. "If your son takes medication, the symptoms can be controlled."
(veracity means to tell the truth. 1. is a therapeutic response. 3. don't ask the pt why or
what made you. 4. opposite of veracity, that is not true.
The client in the psychiatric unit tells a nurse, "Someone just put a bomb under
the couch in the lobby." Which action should the nurse implement first?
1. Look under the couch for a bomb.
2. Implement the bomb scare protocol.
3. Have the staff evacuate the unit.
4. Tell the client there is not a bomb.
Answer:
1. Look under the couch for a bomb. (Assess)
The head nurse in a psychiatric unit in the county emergency department is
assigning client to the staff nurses. Which client should be assigned to the most
experienced nurse?
1. The client who is crying and upset because she was raped.
2. The client diagnosed with bipolar disorder who is agitated.
3. The client who was found wandering the streets in a daze.
4. The client diagnosed with schizophrenia who is hallucinating.
Answer:
3. The client who was found wandering the streets in a daze. (when the Q asks "who
are you going to give to the most experienced nurse" what they are really asking is "who
is the most unstable." "who requires the most in-depth assessment and teaching?" we
know what is wrong with all of these patients, besides #3., we only know the client was
found walking in a daze, we don't know anything about them)
the client diagnosed with anorexia is refusing to eat and is less than 20% of ideal
body weight for her height and structure. The client has not eaten anything since
admission 2 days ago. Which action should the nurse implement?
1. Notify the psychiatrist to request a court order to feed the client.
2. Take no action because the client has the right to refuse treatment.
3. Discharge the client because she is not complying with the treatment.
4. Physically restrain the client and insert a nasogastric tube for feeding.
Answer:
1. Notify the psychiatrist to request a court order to feed the client.
LATEST SOLUTION (ANSWERED)
The nurse is discussing the grieving process with the client. Which stages are
included in Kubler-Ross' stages of grief? Rank in the correct order.
1. Acceptance
2. Bargaining
3. Denial
4. Anger
5. Depression
Answer:
3. Denial
4. Anger
2. Bargaining
5. Depression
1. Acceptance
Which situation requires priority intervention on an inpatient psychiatric unit?
1. A client is threatening to throw the television at another client.
2. A male client wants to use the phone to call his spouse.
3. A client sitting in a chair is delusional and hallucinating
4. A client has refused to eat anything for the last 2 days.
Answer:
1. A client is threatening to throw the television at another client.
The client diagnosed with bipolar disorder and who is prescribed lithium, an anti
mania medication, is admitted to the psychiatric unit in an acute manic state.
Which intervention should the nurse implement first?
1. Have the laboratory draw a STAT serum lithium level.
2. Evaluate what behavior prompted the psychiatric admission.
3. Assess and treat the client's physiological needs.
4. Administer STAT dose of lithium to the client.
Answer:
3. Assess and treat the client's physiological needs.
The psychiatric unit staff is upset about the new female charge nurse who just
sits in her office all day. One of the staff members informs the clinical manager
indicates a laissez-faire leadership style?
1. "I will schedule a meeting to discuss the concerns of the charge nurse."
2. "I hired the new charge nurse and she is doing what I told her to do."
3. "You and the staff really should take care of this situation on your own."
4. "I will talk to the charge nurse about your concerns and get back to you."
Answer:
3. "You and the staff really should take care of this situation on your own."
(laissez-faire attitude is an "everybody is driving their own train" attitude, you guys take
care of it)(option 1. is democratic. 2. is an autocratic style. authoritarian approach. 4. is
taking charge of the situation.)
,The mental health worker reports that one of the nurses threatened to force-fed
the male client diagnosed with schizophrenia if the client did not eat the meal on
the lunch tray. Which action should the charge nurse take first?
1. Tell the MHW that this intervention is part of the client's care plan.
2. Request the nurse to come to the office and discuss the MHW allegation.
3. Ask the client what happened between him and the nurse during lunch.
4. Ask the MHW to write down the situation to submit to the head nurse.
Answer:
2. Request the nurse to come to the office and discuss the MHW allegation.
(never choose an answer like 4. where it suggests you "pass it up" so that you don't
have to deal with the problem. it will be wrong)
The client diagnosed with paranoid schizophrenia is imminently aggressive and
is dangerous to himself, the other clients, and the psychiatric staff members. The
client is placed in a seclusion room. Which interventions should the psychiatric
nurse implement? Select all that apply.
1. Assess the client every 2 hours for side effects of medication.
2. Tell the client what behavior will prompt the release from seclusion.
3. Do not notify the client's family of the initiation of seclusion.
4. Explain that the client will be in seclusion room for 24 hours.
5. Instruct the MHW to check the client every 10-15 minutes.
Answer:
1. Assess the client every 2 hours for side effects of the medication., 2. Tell the client
what behavior will prompt the release from seclusion., 5. Instruct the MHW to check the
client every 10-15 minutes.
The psychiatric nurse overhears a MHW arguing with a client diagnosed with
paranoid schizophrenia. Which action should the nurse implement?
1. Ask the MHW to go to the nurse's station.
2. Tell the MHW to quit arguing with the client.
3. Notify the clinical manager of the psychiatric unit.
4. Report the behavior to the client abuse committee.
Answer:
1. Ask the MHW to go to the nurse's station. (first thing you are going to do is assess
situation with the MHW.)
The psychiatric nurse has taken 15 minutes extra for the lunch break two times in
the last week. Which action should the female clinical manager implement?
1. Take no action and continue to watch the nurse's behavior.
2. Document the behavior in writing and place in the nurse's file.
3. Tell the nurse to check in and out with her when taking lunch.
4. Talk to the nurse informally about taking 45 minutes for lunch.
Answer:
4. Talk to the nurse informally about taking 45 minutes for lunch. (Assess)
The client diagnosed with Alzheimer's disease is on a special unit for clients with
cognitive disorders. Which assessment data would warrant immediate
intervention by the psychiatric nurse?
1. The client does not know his or her name, date, or place.
2. The client is unable to dress himself or herself without assistance.
, 3. The client is difficult to arouse from sleep.
4. The client needs assistance when eating a meal.
Answer:
3. The client is difficult to arouse from sleep.
The mother of a client recently diagnosed with schizophrenia says to the nurse, "I
was afraid of my son. Will he be alright?" Which response by the psychiatric
nurse supports the ethical principal of veracity?
1. "I can see your fear; you are concerned your son will not be alright."
2. "If your son takes medication, the symptoms can be controlled."
3. "Why were you afraid of your son? Did you think he would hurt you?"
4. "Schizophrenia is a mental ill ness and your son will not be alright."
Answer:
2. "If your son takes medication, the symptoms can be controlled."
(veracity means to tell the truth. 1. is a therapeutic response. 3. don't ask the pt why or
what made you. 4. opposite of veracity, that is not true.
The client in the psychiatric unit tells a nurse, "Someone just put a bomb under
the couch in the lobby." Which action should the nurse implement first?
1. Look under the couch for a bomb.
2. Implement the bomb scare protocol.
3. Have the staff evacuate the unit.
4. Tell the client there is not a bomb.
Answer:
1. Look under the couch for a bomb. (Assess)
The head nurse in a psychiatric unit in the county emergency department is
assigning client to the staff nurses. Which client should be assigned to the most
experienced nurse?
1. The client who is crying and upset because she was raped.
2. The client diagnosed with bipolar disorder who is agitated.
3. The client who was found wandering the streets in a daze.
4. The client diagnosed with schizophrenia who is hallucinating.
Answer:
3. The client who was found wandering the streets in a daze. (when the Q asks "who
are you going to give to the most experienced nurse" what they are really asking is "who
is the most unstable." "who requires the most in-depth assessment and teaching?" we
know what is wrong with all of these patients, besides #3., we only know the client was
found walking in a daze, we don't know anything about them)
the client diagnosed with anorexia is refusing to eat and is less than 20% of ideal
body weight for her height and structure. The client has not eaten anything since
admission 2 days ago. Which action should the nurse implement?
1. Notify the psychiatrist to request a court order to feed the client.
2. Take no action because the client has the right to refuse treatment.
3. Discharge the client because she is not complying with the treatment.
4. Physically restrain the client and insert a nasogastric tube for feeding.
Answer:
1. Notify the psychiatrist to request a court order to feed the client.
