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RN HESI MENTAL HEALTH EXAM (3 VERSIONS) QUESTIONS & VERIFIED ANSWERS
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A client with depression remains in bed most of the day, and declines activities. Which nursing problem has the greatest priority for this client? A. Loss of interest in diversional activity. B. Social isolation. C. Refusal to address nutritional needs. D. Low self-esteem. The RN is preparing medications for a client with bipolar disorder and notices that the client discontinued antipsychotic medication for several days. Which medication should also be discontinued? a. Lithium. (Lithotabs) b. Benzotropine (Cogentin). c. Alprazolam (Xanax). d. Magnesium (Milk of Magnesia). The RN is teaching a client about the initiation of the prescribed abstinence therapy using disulfiram (Antabuse). What information should the client acknowledge understanding? A. Completely abstain from heroin or cocaine use. B. Remain alcohol free for 12 hours prior to the first dose. C. Attend monthly meetings of alcoholics anonymous. D. Admit to others that he is a substance user. A male client with schizophrenia is admitted to the mental health unit after abruptly stopping his prescription for ziprasidone (Geodon) one month ago. Which question is most important for the RN to ask the client? A. Have you lost interest in the things that you used to enjoy? B. Is your ability to think or concentrate decreased? C. How many continuous hours do you sleep at night? D. Do you hear sounds or voices that others do not hear? A female client requests that her husband be allowed to stay in the room during the admission assessment. When interviewing the client, the RN notes a discrepancy between the client’s verbal and nonverbal communication. What action does the RN take? A. Pay close attention and document the nonverbal messages.
B. Ask the client’s husband to interpret the discrepancy. C. Ignore the nonverbal behavior and focus on the client’s verbal messages. D. Integrate the verbal and nonverbal messages and interpret them as one. A male client approaches the RN with an angry expression on his face and raises his voice, saying “My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out!” The RN recognizes that the client is using which defense mechanism? A. Denial. B. Projection. C. Rationalization. D. Splitting. A mental health worker is caring for a client with escalating aggressive behavior. Which action by the MHW warrant immediate intervention by the RN? A. Is attempting to physically restrain the patient. B. Tells the client to go to the quiet area of the unit. C. Is using a loid voice to talk to the client. D. Remains at a distance of 4 feet from the client. A client on the mental health unit is becoming more agitated, shouting at the staff, and pacing in the hallway. When the PRN medication is offered, the client refuses the medication and defiantly sits on the floor in the middle of the unit hallway. What nursing intervention should the RN implement first? A. Transport of the client to the seclusion room. B. Quietly approach the client with additional staff members. C. Take other clients in the area to the client lounge. D. Administer medication to chemically restrain the patient. A male client with bipolar disorder who began taking lithium carbonate five days ago is complaining of excessive thirst, and the RN finds him attempting to drink water from the bathroom sink faucet. Which intervention should the RN implement? A. Report the client’s serum lithium level to the HCP. B. Encourage the client to suck on hard candy to relieve the symptoms. C. No action is needed since polydipsia is a common side effect. D. Tell the client that drinking from the faucet is not allowed. During an annual physical by the occupational RN working in a corporate clinic, a male employee tells the RN that is high-stress job is causing trouble in his personal life. He further
employees are referred for counseling with the staff psychiatric RN. Which factor in the pushed employee’s history is most related to the reaction that occurred? A. Is worried about losing his job to a woman. B. Tortured animals as a child. C. Was physically abused by his mother. D. Hates to be touched by anyone. The RN documents the mental status of a female client who has been hospitalized for several days by court order. The client states, “I don’t need to be here” and tells the RN that she believes the television talks to her. The RN should document these assessment findings in which section of the mental status exam/ A. Level of concentration. B. Insight and judgement. C. Remote memory. D. Mood and affect. A client is admitted to the mental health unit reports shortness of breath and dizziness. The client tells the RN, “I feel like I’m going to die”. Which nursing problem should the RN include in this client’s plan of care? A. Mood disturbance. B. Moderate anxiety. C. Altered thoughts. D. Social isolation. A female client who is wearing dirty clothes and has foul body odor, comes to the clinic reporting feeling scared because she is being stalked. What action is most important for the RN to take? A. Offer the client a safe place to relax before interviewing her. B. Ask the client to describe why she is being stalked. C. Recommend that the client talk with a social worker. D. Assure the client that the HCP will see her today. The RN leading a group session of adolescent clients gives the members a handout about anger management. One of the male clients is fidgety, interrupts peers when they try and talk, and talks about his pets at home. What nursing action is best for the RN to take? A. Explore the client’s feelings about his pets and home life. B. Encourage his peers to help involve him in the activity. C. Give the client permission to leave and return in 10 minutes. D. Redirect him by encouraging him to read from the handout.
A male adolescent was admitted to the unit two days ago for depression. When the mental health RN tries to interview the client to establish rapport, he becomes very irritated and sarcastic. Which action is best for the RN to take? A. Report the behavior to the next shift. B. Offer to play a game of cards with the client. C. Document the behavior in the chart. D. Plan to talk with the client the next day. A male adult is admitted because of an acetaminophen (Tylenol) overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client's discharge plan? A. Do not take any over the counter meds. B. Eat a high carb, low fat, low protein diet. C. Call the crisis hotline if feeling lonely. D. Avoid exposure to large crowds. After receiving treatment for anorexia, a student asks the school RN for permission to work in the school cafeteria as part of the school’s work study program. What action should the RN take? A. Refer the student to a psychiatrist for further discussion. B. Recommend assignment to the receptionist’s office. C. Suggest that student work in the athletic department. D. Determine the parent’s opinion of the work assignment. The Rn accepts a transfer to the metal health unit and understands that the client is distractible and is exhibiting a decreased ability to concentrate. The RN only has 15 minutes to talk to the client. To develop treatment plan for this client, which assessment is most important for the RN to obtain? A. Motivation of treatment. B. History of substance use. C. Medication compliance. D. Mental status examination. A male client who recently lost a loved one arrives at the mental health center and tells the RN he is no longer interested is his usual activities and has not slept for several days. Which priority nursing problem should the RN include in the client’s plan of care? A. Risk for suicide. B. Sleep deprivation. C. Situational low self-esteem. D. Social isolation.
A. Reassure the client that his request will be met whenever possible. B. Advise the client that assignments are not based on the client’s request. C. Ask the client to explain why he constantly requests the RN. D. Encourage the client to verbalize his feelings about the RN. When preparing to administer a prescribed medication to a homeless male at a community clinic, the client tells the RN that he usually takes a different dosage. What action should the RN take? A. Tell him to take the medication then verify the dosage at the next healthcare team meeting. B. Withhold the medication until the dosage can be confirmed. C. Inform him that he may refuse the medication and document whether or not he takes it. D. Explain to the client that the dosage has been changed. The nurse orients a female client with depression to the new room on the mental health unit. The client states “It seems strange that I don’t have a T.V in my room.” Which statement would be best for the RN to provide? A. “You can watch T.V as much as you want outside of your room.” B. “Sometimes clients feel like the T.V is sending them messages.” C. “It’s important to be out of you room and talking to others.” D. “Watching T.V is a passive activity and we want you to be active.” A client admitted with a closed head injury after a fall has a blood alcohol level of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the RN identify as the priority? A. Give lorazepam (Ativan) PRN for signs of withdrawal. B. Administer disulfiram (Antabuse) immediately. C. Place in a side lying position with head of bed elevated. D. Provide thiamine and folate supplements as prescribed. The RN is completing the admission assessment of an underweight adolescent who is admitted to a psychiatric unit with a diagnosis of depression. Which finding requires notification to the HCP? A. Potassium level of 2.9 mEq/dl. B. Blood pressure of 110/70 mmHg. C. WBC of 10,000mm^3. D. Body mass index of 21. The Rn is planning client teaching for a 35 - year-old client with alcoholic cirrhosis. Which self- care measure should the RN emphasize for the client’s recovery? A. Support group meetings. B. Vitamin B and multivitamin supplements.
C. Diet with adequate calories and protein. D. Alcohol abstinence. A teenager has lost 20 pounds in the last three months is admitted to the hospital with hypotension and tachycardia. The client reports irregular menses and hair loss. Which intervention is most important for the RN to include in the clients plan of care? A. Implement behavioral modification therapy. B. Initiate caloric and nutritional therapy. C. Evaluate the client for low self-esteem. D. Record daily weights and graft trend. While interviewing a client, the nurse takes notes to assist with accurate documentation later. Which statement is most accurate regarding note-taking during an interview? A. The client’s comfort level is increased when the RN breaks eye contact to take notes. B. The interview process is enhanced with note taking and allows the client to speak at a normal pace. C. Taking notes during an interview is a legal obligation of examining RN. D. The RN’s ability to directly observe the client’s non-verbal communication is limited with note taking. A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care? a. Client will not demonstrate cross addiction. b. Co-dependent behaviors will be decreased. c. CNS stimulation will be reduced. d. Client's level of consciousness will increase. A client who is being treated with lithium carbonate for manic depression begins to develop diarrhea, vomiting, and drowsiness. What action should the nurse take? a. Notify the physician immediately and force fluids. b. Prior to giving the next dose, notify the physician of the symptoms. c. Record the symptoms and continue medication as prescribed. d. Hold the medication and refuse to administer additional amounts of the drug. While caring for an older client, the RN observes multiple bruises in Over the client’s legs, arms, back, and gluteal areas. When the client Contact, the RN suspects elder abuse. What action should the RN take? A. Report family conversations and anger towards the client when visiting. B. Ask the client specific questions about someone causing the bruising. C. Question the family members and caregiver how the bruising occurred.
C. Schedule activity therapy twice a week. D. Confront his delusion as not consistent with reality. The RN on the day shift receive report about a client with depression who was in bed most of the weekend. The RN walks into the client’s room in the morning and finds the client in bed. What intervention is best for the RN to implement? A. Monitor the client’s appetite and pattern of sleep. B. Assess the client’s feelings about the hospital stay. C. Assist the client to get out of bed and involved in an activity. D. Explain that staff will check on the client every 30 minutes. Which client information indicates the need for the RN to use CAGE questionnaire during the admission interview? A. Client’s medication history includes the frequent use of antidepressants. B. Describe self as a social drinker who drinks alcoholic beverages daily. C. Reports difficulties with short term memory since traumatic brain injury. D. Medical history includes that the client was recently sexually assaulted. A female client admitted to the mental health unit starts to shout and scream at the RN. What is the best approach for the RN to take? A. Stay quietly with the patient B. Tell her that she is out of control. C. Distract her by offering her finger foods. D. Ignore the client’s acting out behavior. A woman is brought to the psychiatric clinic by her husband. He reports that his wife is reluctant to leave home because of what she describes as a fear of open places and crowds. Which nursing problem applies to this client’s behavior? A. Ineffective protection to guard self from internal or external threats. B. Risk for injury related to inability to communicate. C. Risk prone health behavior related to self-esteem assault. D. Anxiety related to real or perceived threat to physical integrity. A client is receiving benztropine mesylate (Cogentin) for drug-induced extrapyramidal syndrome (EPS). Which finding indicates that the RN should further evaluate the client? A. Decreased bowel movements. B. Presence of a dry mouth. C. Decreasing hand tremors. D. Increased mouth movements.
A male client in the mental health unit is guarded and vaguely answers the nurse’s questions. He isolates in his room and sometimes opens the door to peek into the hall. Which problem can the RN anticipate? A. Visual hallucinations. B. Auditory hallucinations. C. Excessive motor activity. D. Delusions of persecution. A female client with obsessive compulsive personality disorder is admitted to the hospital for a cardiac catheterization. The afternoon before the procedure, the client begins to keep detailed notes of the nursing care she is receiving, and reports her findings to the RN at bedtime. What action should the nurse implement? A. Explain to the client that her behavior invades the rights of the nursing staff. B. Ask the client to explain why she is keeping a detailed record of her nursing care. C. Teach the client strategies to control her obsessive compulsive behavior. D. Encourage the client to express her feelings regarding the upcoming procedure. During admission to the psychiatric unit, a female client is extremely anxious and states that she is worried about the sun coming up the next day. What intervention is most important for the RN to implement during the admission process? A. Assist the client in developing alternative coping skills. B. Remain calm and use a matter of fact approach. C. Ask the client why she is so anxious D. Administer a PRN sedative to help relieve her anxiety. A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The RN also determines that the client is homeless and is exhibiting suspiciousness. The client’s plan of care should include what priority problem? A. Acute confusion. B. Ineffective community coping C. Disturbed sensory perception. D. Self-care deficit. The occupational health nurse is working with a female employee who was just notified that her child was involved in a MVA and taken to the hospital. The employee states, “I can’t believe this. What should I do?” Which response is best for the RN to provide in this crisis? A. Tell me what you think should happen. B. How serious was the collision? C. What do you think you should do?
A young adult female visits the mental health clinic complaining of diarrhea, headache, and muscle aches. She is afebrile, denies chills, and all laboratory findings are within normal limits. During the physical assessment, the client tells the RN that her sister thinks she is neurotic and calls her a hypochondriac. Which response is best for the RN to provide? A. Unless your sister has a medical education, ignore her comments. B. I can hear that your sister comments are over-whelming you. C. Do you think it’s possible that you might be a hypochondriac? D. Besides your sister’s comments, what in your life is troubling you? The RN is leading a group on the inpatient psychiatric unit. Which approach should the RN use during the working phase of group development? A. Establishing a rapport with group members. B. Clarifying the nurse’s role and clients’ responsibilities. C. Discussing ways to use new coping skills learned. D. Helping clients identify areas of problem in their lives. A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. What intervention is best for the RN to implement? A. Isolate the client from the other clients. B. Administer PRN sedative. C. Avoid recognizing the behavior. D. Escort the client to his room. A client is admitted for bipolar disorder and alcohol withdrawal, depressive phase. Based on which assessment finding will the RN withhold the clonidine (Catapres) prescription? A. Blood pressure readings of 90/62 mmHg to 92/58 mmHg. B. Pulse rate of 68 - 78 BPM. C. Temperature of 99.5-99.7 F. D. Respiration rate of 24 breaths per minute. The RN on the evening shift receives report that a client is scheduled for electroconvulsive treatment (ECT) in the morning. Which intervention should the Rn implement the evening before the scheduled ECT? A. Hold all bedtime medications. B. Keep the client NPO after mid-night. C. Implement elopement precautions.
D. Give the client an enema at bedtime. A client with Bulimia and depression who is taking phenelzine (Nardil) 90 mg daily is admitted to an acute care hospital for uncontrolled hypertension. What dietary choices should the RN instruct the client to avoid? A. Pan-seared catfish. B. Peperoni pizza. C. Deep fried shrimp. D. Beef trips with gravy. A mental health worker is caring for a client with escalating aggressive behavior. Which action by the mental health worker warrants immediate intervention by the RN? A. Is attempting the physically restrain the patient. B. Remains at a distance of 4 feet from the client. C. Tells the client to go to the quiet area of the unit. D. Is using a load voice to talk to the client. A client who recently experienced the death of a significant other arrives at the mental health center. The client reports loss of interest in usual activities, expresses a wish to be with the decreased significant other, has been eating very little, and has not slept in several days. Which client statement is most important for the RN to explore at this time? A. Not sleeping for several days. B. Wishing to be with spouse. C. Lack of interest in usual activities. D. Eating very little. A middle aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and motivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning? A. Provide education on methods to enhance sleep. B. Teach the client to develop a plan for daily structured activities. C. Suggest that the client develop a list of pleasurable activities. D. Encourage the client to exercise. When developing a plan of care for a client admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing problem has the highest priority? A. Impaired comfort. B. Risk for injury.
in the sink and on the floors, and the toilet stopped up with tissue, paper towels, and feces. What is the priority issue that the RN should address? A. Medication non-compliance. B. Number of bathroom facilities. C. Infection control. D. Acting out behaviors. A client with schizophrenia is admitted to the psychiatric care unit for aggressive behavior, auditory hallucinations, and potential for safe harm. The client has not been taking medications as prescribed and insists that the food has been poisoned and refuses to eat. What intervention should the RN implement? A. Assure the client that all food served in the hospital is safe to eat. B. Tell the client that irrational thinking is a symptom of schizophrenia. C. Obtain an order for a tube feeding for the client. D. Provide the client with food in unopened containers. The RN is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? (SOA) A. Purchase a gun to use for protection. B. Establish a code with family and friends to signify violence. C. Take a self-defense course that retaliates the abuser with injury. D. Have a bag ready that has extra clothes for self and children. E. Plan an escape route to use if the abuser blocks the main exit. The RN is admitting a male client who take lithium carbonate (Eskalith) twice a day. Which information should the RN report to the HCP immediately? A. Short term memory loss. B. Five pound weight gain C. Decreased affect. D. Nausea and vomiting. A male client who is admitted with delirium tremens is dehydrated and experiencing auditory hallucinations. He has a bruised, swollen tongue and is confused. In developing a plan of care, which action should the RN include to ensure the client is physiologically stable? A. Encourage oral fluids. B. Monitor vital signs. C. Keep the room dark. D. Apply ice to his tongue.
A RN is teaching a client about initiation of a prescribed abstinence therapy using Disulfiram (Antabuse). What information should the client acknowledge understanding? A. Admit to others that he is a substance abuser. B. Remain alcohol free for 12 hours prior to first dose. C. Attend monthly meetings of alcoholics anonymous. D. Completely sustain from heroin or cocaine use. The RN is working with a male client at a community mental health center when the client reports hearing voices that tell him to get a knife from the kitchen and hurt himself. What intervention is most important for the RN to implement? A. Don’t allow the client to go into the kitchen until the hallucination has subsided. B. Report the behavior to the client’s case workers so that the family can be notified. C. Assign the UAP to remain with the client at all times. D. Document the behavior in the client’s record and notify the HCP. A homeless client who reports feeling sad and depressed tells the mental health nurse that in the past 2 days she has only had 4 hours of sleep. Which action is most important for the RN to implement within the first 24 hours after treatment is initiated? A. Allow the client to rest and sleep. B. Ensure client attend groups addressing coping skills for dealing with depression. C. Begin planning for the clients discharge. D. Encourage verbalization of feelings. Which client statement suggests the RN that the client is using a defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit? A. At least I hit the wall instead of hitting the psychiatric aide. B. I am here because the police thought I was doing something wrong. C. I want to be here because I know it is the best psychiatric facility. D. Don’t believe everything my family tells you, I am not crazy. A male client is admitted to the psychiatric inpatient unit with a bandaged flesh wound after attempting to shoot himself. He was divorced one year ago. Lost his job four months ago, and suffered a breakup of is current relationship last week. What is most likely source of this client’s current feelings of depression? A. Feelings of frustration. B. A sense of loss C. Poor self-esteem. D. A lack of intimate relationships. The RN documents the mental status of a female client who has been hospitalized for several days by court order. The client states”I don’t need to be here,” and tells the RN that she believes that the t.v talks to her. The RN should document these assessment statements in which section of the mental status exam?
Patient says “I'm going to shoot myself” a. Stop the client from leaving the unit A client who is known to abuse drugs is admitted to the psychiatric unit. Which medication should the nurse anticipate administering to a client who is exhibiting benzodiazepine withdrawal symptoms? a. Perphenazine (Trilafon). b. Diphenylhydramine (Benadryl). c. Chlordiazepoxide (Librium). d. Isocarboxazid (Marplan). A woman brings her 48-year-old husband to the outpatient psychiatric unit and describes his behavior to the admitting nurse. She states that he has been sleepwalking, cannot remember who he is, and exhibits multiple personalities. The nurse knows that these behaviors are often associated with which condition? a. Dissociative disorder. b. Obsessive-compulsive disorder. c. Panic disorder. d. Post-traumatic stress syndrome. Which diet selection by a depressed client taking tranylcypromine sulfate (Parnate), an MAO inhibitor, indicates to the nurse that the client understands the dietary restrictions imposed by this medication regimen? a. Hamburger, french fries, and chocolate milkshake. b. Liver and onions, broccoli, and decaffeinated coffee. c. Pepperoni and cheese pizza, tossed salad, and soda. d. Roast beef, baked potato with butter, and iced tea. A female client on a psychiatric unit is sweating profusely while she vigorously does pushups and then runs the length of the corridor several times before crashing in to the furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbances, the client shouts," I am the boss here. I do what I want." Which nursing problem best supports these observations
ECT therapy is not working, pt is non responsive to treatment what question should the nurse ask?