Download HESI Mental Health (PSYCH) Final PRACTICE 2025.pdf and more Exams Nursing in PDF only on Docsity!
HESI Mental Health (PSYCH) Final PRACTICE 202 5 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.
- Acceptance
- Bargaining
- Denial
- Anger
- Depression - Answer:
- Denial
- Anger
- Bargaining
- Depression
- Acceptance Which situation requires priority intervention on an inpatient psychiatric unit?
- A client is threatening to throw the television at another client.
- A male client wants to use the phone to call his spouse.
- A client sitting in a chair is delusional and hallucinating
- A client has refused to eat anything for the last 2 days. - Answer:
- 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?
- Have the laboratory draw a STAT serum lithium level.
- Evaluate what behavior prompted the psychiatric admission.
- Assess and treat the client's physiological needs.
- Administer STAT dose of lithium to the client. - Answer:
- 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?
- "I will schedule a meeting to discuss the concerns of the charge nurse."
- "I hired the new charge nurse and she is doing what I told her to do."
- "You and the staff really should take care of this situation on your own."
- "I will talk to the charge nurse about your concerns and get back to you." - Answer:
- "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?
- Tell the MHW that this intervention is part of the client's care plan.
- Request the nurse to come to the office and discuss the MHW allegation.
- Ask the client what happened between him and the nurse during lunch.
- Ask the MHW to write down the situation to submit to the head nurse. - Answer:
- 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)
Answer:
- 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?
- The client does not know his or her name, date, or place.
- The client is unable to dress himself or herself without assistance.
- The client is difficult to arouse from sleep.
- The client needs assistance when eating a meal. - Answer:
- 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?
- "I can see your fear; you are concerned your son will not be alright."
- "If your son takes medication, the symptoms can be controlled."
- "Why were you afraid of your son? Did you think he would hurt you?"
- "Schizophrenia is a mental ill ness and your son will not be alright." - Answer:
- "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?
- Look under the couch for a bomb.
- Implement the bomb scare protocol.
- Have the staff evacuate the unit.
- Tell the client there is not a bomb. - Answer:
- 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?
- The client who is crying and upset because she was raped.
- The client diagnosed with bipolar disorder who is agitated.
- The client who was found wandering the streets in a daze.
- The client diagnosed with schizophrenia who is hallucinating. - Answer:
- 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?
- Notify the psychiatrist to request a court order to feed the client.
- Take no action because the client has the right to refuse treatment.
- Discharge the client because she is not complying with the treatment.
- Physically restrain the client and insert a nasogastric tube for feeding. - Answer:
- Notify the psychiatrist to request a court order to feed the client. The nurse answers the client's phone in the lobby area and the person asks, "May I speak to Mr. Jones?" Which action should the nurse implement?
A highly agitated client paces the unit and states. "I could buy and sell this place." The client's mood fluctuates rom fits of laughter to outbursts of anger. Which is the most accurate documentation of this client's behavior? A. "Rates mood 8/10. Exhibiting looseness of association. Euphoric." B. "Mood euthymic. Exhibiting magical thinking. Restless." C. "Mood labile. Exhibiting delusions of reference. Hyperactive." D. "Agitated and pacing. Exhibiting grandiosity. Mood labile." - Answer: D. "Agitated and pacing. Exhibiting grandiosity. Mood labile." A client diagnosed with bipolar disorder is distraught over insomnia experienced over the last 3 nights and a 12- pound weight loss over the past 2 weeks. Which should be this client's priority nursing diagnosis? A. Knowledge deficit R/T bipolar disorder AEB concern about symptoms. B. Altered nutrition: Less than body requirements r/t hyperactivity AEB weight loss. C. Risk for suicide r/t powerlessness AEB insomnia and anorexia. D. Altered sleep patterns r/t mania AEB insomnia for the past 3 nights. - Answer: B. Altered nutrition: Less than body requirements r/t hyperactivity AEB weight loss. (physical needs/health always priority.) A nurse is planning care for a client diagnosed with bipolar disorder: manic phase. In which order should the nurse prioritize the client outcomes in the exhibit? Client outcomes:
- Maintains nutritional status.
- Interacts appropriately with peers.
- Remains free from injury.
- Sleeps 6-8 hrs at night. - Answer:
A client diagnosed with bipolar disorder: depressive phase intentionally overdoses on sertraline (Zoloft). Family members report that the client has experience anorexia, insomnia, and recent job loss. What should be the priority nursing diagnosis for this client? A. Risk for suicide r/t hopelessness. B. Anxiety: severe r/t hyperactivity C. Imbalanced nutrition: less than body requirements r/t refusal to eat D. Dysfunctional grieving r/t loss of employment. - Answer: A. Risk for suicide r/t hopelessness. A client diagnosed with BP disorder: manic episode refuses to take lithium carbonate due to excessive weight gain. in order to increase compliance, which medication should a nurse anticipate that a physician will prescribe? A. Sertraline (Zoloft) B. Valporic acid (Depakote) C. Trazodone (Desyrel) D. Paroxetine (Paxil) - Answer: B. Valporic acid (Depakote) (prescribed to help with weight loss.) A client diagnosed with BP disorder is exhibiting severe manic behaviors. A physician prescribes lithium carbonate (Eskalith) and olanzapine (Zyprexa). The client's spouse questions the Zyprexa order. Which is the appropriate nursing response? A. "Zyprexa in combination with Eskalith cures manic symptoms." B. "Zyprexa prevents extrapyramidal side effects."
A nursing instructor is discussing various challenges in the treatment of clients diagnosed with bp disorder. Which student statement demonstrates an understanding of the most critical challenge in the care of these clients? A. "Treatment is compromised when clients can't sleep." B. "Treatment is compromised with irritability interferes with social interactions." C. "Treatment is compromised when clients have no insight into their problems." D. "Treatment is compromised when clients choose not to take their medications." - Answer: D. "Treatment is compromised when clients choose not to take their medications." A clients diagnosed with bp disorder: manic phase. Which nursing intervention would be implemented to achieve the outcome of "Client will gain 2 lb by the end of the week?" A. Provide client with high-calorie finger foods throughout the day. B. Accompany client to cafeteria to encourage adequate dietary consumption. C. Initiate total parenteral nutrition to meet dietary needs. D. Teach the importance of a varied diet to meet nutritional needs. - Answer: A. Provide client with high-calorie finger foods throughout the day. (Pt is in manic phase. Finger foods will be best for them because pt cannot sit down and eat a meal, they will not slow down or stop long enough to eat a meal.) A nurse discovers a client's suicide note that details the time, place, and means to commit suicide. What should be the priority nursing action and why? A. Administering lorazepam (Ativan) prn, because the client is angry at exposure of plan. B. Establishing room restrictions, because the client's threat is an attempt to manipulate the staff. C. Placing this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide.
D. Calling an emergency treatment team meeting, because the client's threat must be addressed. - Answer: C. Placing this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide. (First question: are you suicidal? Second: Do you have a plan? third: What is your plan? Important to assess the details of the plan. Immediately after electroconvulsive therapy, in which position should a nurse place the client? A. On his or her side to prevent aspiration. B. In high Fowler's position to promote consciousness. C. In Trendlenburg's posiiton to promote blood flow to vital organs. D. In prone position to prevent airway blockage. - Answer: A. On his or her side to prevent aspiration. A client is diagnosed with major depressive disorder. Which nursing diagnosis should a nurse assign to this client to address a behavioral symptom of this disorder? A. Altered communication r/t feelings of worthlessness AEB anhedonia. B. Social isolation r/t poor self-esteem AEB secluding self in room. C. Altered thought processes r/t hopelessness AEB persecutory delusion. D. Altered nutrition: less than body requirements r/t high anxiety AEB anorexia. - Answer: B. Social isolation r/t poor self-esteem AEB secluding self in room. (KEY: question asked for BEHAVIORAL symptom.) A client diagnosed with major depression with psychotic features hears voices commanding self-harm. A nurse is unable to elicit a contract for safety. What should be the nurse's priority intervention at this time?
(No miraculous healing occurs, in 4 wks pt will not recieve effects from medication. They may have come up with a fool proof suicide plan. Pay attention to time frame that question gives you such as "1 month") What is the rationale for a nurse to perform a full physical health assessment on a client admitted with a diagnosis of major depressive disorder? A. The attention during the assessment is beneficial in decreasing social isolation. B. Depression can generate somatic symptoms that can mask actual physical disorders. C. Physical health complications are likely to arise form antidepressant therapy. D. Depressed clients avoid addressing physical health and ignore medical problems. - Answer: B. Depression can generate somatic symptoms that can mask actual physical disorders. (Concept of this question is a popular mental health question.) A nurse is planning care for a child who is experiencing depression. Which medication is approved by the FDA for the treatment of depression in children and adolescents? A. Paroxetine (Paxil) B. Sertraline (Zoloft) C. Citalopram (Celexa) D. Fluoxetine (Prozac) - Answer: D. Fluoxetine (Prozac) (Famous HESI, NCLEX question. SSRI is first line treatment for depression) A nurse recently admitted a client to an inpatient unit after a suicide attempt. A health-care provider orders amitriptyline (Elavil) for the client. Which intervention,
related to this medication, should be initiated to maintain this client's safety upon discharge? A. Provide a 6-month supply of Elavil to ensure long-term compliance. B. Provide a 1-wk supply of Elavil with refills contingent on follow-up appointments. C. Provide pill dispenser as a memory aid. D. Provide education regarding the avoidance of foods containing tyramine. - Answer: B. Provide a 1-wk supply of Elavil with refills contingent on follow-up appointments. (followup is good for assessment, don't want to give enough supply for them to take all at once and overdose.) A client who has been taking fluvoxamine (Luvox) without improvement asks a nurse "I heard about something called a monoamine oxidase inhibitor (MAOI). Cant my doctor add that to my medications?" Which is an appropriate nursing response? A. "This combination of drugs can lead to delirium tremens." B. "A combination of an MAOI and Luvox can lead to a life-threatening hypertensive crisis." C. "Thats a good idea. There have been good results with the combination of these two drugs." D. "The only disadvantage would be the exorbitant cost of the MAOI." - Answer: B. "A combination of an MAOI and Luvox can lead to a life-threatening hypertensive crisis." (MAOI have many interactions. Prescribers avoid prescribing MAOIs) A psychiatrist prescribes a monoamine oxidase inhibitor for a client. Which foods should the nurse teach the client to avoid? A. Pepperoni pizza and red wine. B. Bagels with cream cheese and tea. C. Apple pie and coffee.
state that no phone calls are permitted after 10:00 p.m. Which nursing response is most appropriate? A. "Go ahead and use the phone. I know this pending divorce is stressful." B. "You know better than break the rules. Im surprised at you. " C. "It is after the 10:00 p.m. phone curfew. You will be able to call tomorrow." D. "The decision to divorce should not be considered until you have had a good nights sleep." - Answer: C. "It is after the 10:00 p.m. phone curfew. You will be able to call tomorrow." A client diagnosed with paranoid personality disorder becomes violent on a unit. Which nursing intervention is most appropriate? A. Provide objective evidence that reasons for violence are unwarranted. B. Initially restrain the client to maintain safety. C. Use clear, calm, statements and a confident physical stance. D. Empathize with the client's paranoid perceptions. - Answer: C. Use clear, calm, statements and a confident physical stance. (First thing you are going to do when a pt becomes violent, you are going to firmly and calmly let the pt know that they need to calm down. If necessary, restrain pt.) A highly emotional client presents at an outpatient clinic appointment wearing flamboyant attire, spiked heels, and theatrical makeup. Which personality disorder should a nurse associate with this behavior? A. Compulsive personality disorder B. Schizotypal personality disorder C. Histrionic personality disorder D. Manic personality disorder - Answer: C. Histrionic personality disorder
(Histrionic are the drama queens, attention seeker. Underlying issue with compulsive disorder is anxiety. Schizotypal disorder, baseline is psychosis. Manic disorder are pts who are on level 100 all of the time.) A client diagnosed with borderline personality disorder brings up a conflict with the staff in a community meeting and develops a following of clients who unreasonably demand modification of unit rules. How can the nursing staff best handle this situation? A. Allow the clients to apply the democratic process when developing unit rules. B. Maintain consistency of care by open communication to avoid staff manipulation. C. Allow the client spokesman to verbalize concerns during a unit staff meeting. D. Maintain unit order by the application of autocratic leadership. - Answer: B. Maintain consistency of care by open communication to avoid staff manipulation. (borderline personality disorder is very manipulative. They want to cause splitting which looks like pitting the nurses against each other, or one day you are the best nurse ever and then the next day you are the worst nurse in the world.) Which nursing approach should be utilized to maintain a therapeutic relationship with a client diagnosed with borderline personality disorder? A. Being firm, consistent, and empathetic while addressing specific client behaviors. B. Promoting client self-expression by implementing laissez-faire leadership. C. Using authoritative leadership to help clients learn to conform to society norms. D. Overlooking inappropriate behaviors to avoid providing secondary gains. - Answer: A. Being firm, consistent, and empathetic while addressing specific client behaviors. Which adult client should a nurse identify as exhibiting the characteristics of a dependent personality disorder?
A nursing instructor is teaching students about clients diagnosed with histrionic personality disorder and the quality of their relationships. Which student statement indicates that learning has occurred? A. Their dramatic style tends to make their interpersonal relationships quite interesting and fulfilling. B. Their interpersonal relationships tend to be shallow and fleeting, serving their dependency needs. C. They tend to develop few relationships because they are strongly independent but generally maintain deep affection. D. They pay particular attention to details, which can frustrate the development of relationships. - Answer: B. Their interpersonal relationships tend to be shallow and fleeting, serving their dependency needs. (Histrionic disorder: attention seekers, will do anything for attention.) When planning care for a patient diagnosed with borderline personality disorder, which self-harm behavior should a nurse expect the client to exhibit? A. The use of highly lethal methods to commit suicide. B. The use of suicidal gestures to elicit a rescue response from others. C. The use of isolation and starvation as suicidal methods. D. The use of self-mutilation to decreased endorphins in the body. - Answer: B. The use of suicidal gestures to elicit a rescue response from others. Which nursing diagnosis should be prioritized when providing nursing care to a client diagnosed with paranoid personality disorder? A. Risk for violence: directed toward others r/t paranoid thinking. B. Risk for suicide r/t altered thought C. Altered sensory perception r/t increased levels of anxiety
D. Suicidal isolation r/t inability to relate to others. - Answer: A. risk for violence: directed toward others r/t paranoid thinking. A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this client's safety? A. Assess for medication noncompliance. B. Note escalating behaviors and intervene immediately. C. Interpret attempts at communication. D. Assess triggers for bizarre, inappropriate behaviors. - Answer: B. Note escalating behaviors and intervene immediately. (ex escalating behaviors: pacing, hand tapping or fidgeting, facial expression. Other options are not as big of a priority.) A client diagnosed with schizoaffective disorder is admitted for social skills training. Which information should be included in the nurse's teaching? A. The side effects of medications. B. Deep breathing techniques to decrease stress C. How to make eye contact when communicating D. How to be a leader. - Answer: C. How to make eye contact when communicating (Look at the question, it asks for social skills training. All are good answers, test writers try and trick you.) A client diagnosed with schizophrenia tells a nurse, "The Shopatouliens took my shoes out of my room last night". Which is an appropriate charting entry to describe this client's statement? A. "The client is experiencing command hallucinations"
