HESI-Focus on Mental Health

a client with delirium suddenly picks up a can of soda from a meal tray and threatens to throw it at the nurse. How should the nurse respond

"Hitting me or anyone else is not allowed"

a client with OCD, is upset and agitated, walks repeatedly around the nursing unit, following the same route each time. The client says to the nurse, "walk with me". Which response by the nurse is approrpaite

"I can see that you're upset. I can walk and talk with you for 15min"

a nurse uses the proverb, "People in glass houses shouldn't throw stones" to assess the abstract thinking ability of a client with schizophrenia. Which response by the client demonstrates that the capacity for abstract thinking is intact

"I shouldn't tell someone not to do something that I'm doing myself"

a home health nurse provides instructions to the spouse of a client taking tacrine hydrochloride for the mgmt of moderate dementia associated with Alzheimer's Disease. Which information should the nurse provide to the spouse

"If you see a change in the color of the skin or stool, notify the HCP"

a client states to a nurse, "I feel like putting an end to my misery". How should the nurse respond to the client

"Tell me more about what you feel like doing"

a psych nurse is sitting with several clients in the day room. A client who has been experiencing delusions and hallucinations says to the nurse, "That television is sending special messages to me." Which of the following responses by the nurse is therapeutic

"The television is on for everyone"

a client diagnosed with schizophrenia tells the nurse. "There are voices outside the window telling me what to do all the time. Can you hear them? What should I tell them?" How should the nurse respond initially

"What are the voices telling you?"

a nurse is caring for a client hospitalized with depression. Which comment by the nurse upon entering the client's room is appropriate

"You're wearing a new dress this morning"

a client in the mental health unit points to another client and says to the nurse, "He's been working with the Taliban, pouring anthrax into our water supple". How should the nurse respond to the client

"are you saying that you don't feel safe about drinking our water?"

after an attack in a park while jogging, a client experiences PTSD. The client, visibly anxious, tells the nurse that she now avoids all exercise and parks but says, "I don't want to feel this way". Which response by the nurse is appropriate

I can see that you're upset about this. Let's talk some more about it

a client who is hallucinating fearfully says to the nurse, "Please tell that demon to get out." How should the nurse respond to the client

I know you must be very upset by this, but I don't see a demon

a client says, "I spend hours each evening reviewing my day to see whether I behaved appropriately or should have done something differently. I tell myself to snap out of it, but I'm still doing it! It takes me 2 or 3 hours each morning to get dressed b/c I want my clothes to be just right." Which problem is evident in these statements

OCD

a nurse cares for a hospitalized client who has been taking clozapine for the tx of schizophrenia. Which lab result will the nurse specifically check to assess the client for an adverse reaction associated with the use of this med

WBC

a nurse prepares a client for ECT. Which concern is of the highest priority

risk of aspiration

a client is unwilling to leave the house for fear of doing "something bizarre in public". As result, the client remains homebound expect when accompanied by her husband. The nurse analyzes the data and determines that the client is experiencing

agoraphobia

a nurse assists in caring for victims of an explosion at a local industrial plant. the nurse plans to implement crisis interventions, knowing that this incident is characteristic of

an adventitious crisis

a client whose spouse died is experiencing dysfunctional grieving. Which intervention has priority in the plan of care

assessing the client's risk for violence toward self and others

a nurse completes the initial assessment for a new client in a maximum security prison who has been sentenced to serve a life sentence w/o parole. What should the nurse include as a priority in the tx plan for this client

assessment for suicide risk

a nurse in a women's clinic develops a plan of care for abused women. Which tertiary prevention intervention should be included in the plan of care

assisting abused women in overcoming the physical and psychological effects of abuse

a nurse provides medication instructions to a client who is taking lithium carbonate. Which statements by the client indicate an understanding of the instructions SATA a) I should weigh myself several times a day b) I should take this med with my meals c) I need to cut down my fluid intake while I'm taking the med d) I need to call my HCP if I get diarrhea or vomiting or start to sweat a lot e) My blood level of medication needs to be monitored closely while I take this med

b, d, e

a nurse provides dietary instructions to a client who will be taking tranylcypromine. Which foods should the nurse tell the client to avoid SATA a) broccoli b) avocado c) cream cheese d) red meat e) pickled herring

b, e

a drunken client is awaiting tx in the ED. The client becomes loud and aggressive when told that there will be a short delay before tx. Which response by the nurse is therapeutic

offering to take the client to an exam room until tx can be started

a psych nurse who is a member of a mobile crisis team is called to deal with a person who is threatening to jump off a bridge in a suicide attempt. On arrival at the site, the nurse immediately

tries to communicate with the client and develop a therapeutic relationship

a client has a dx of dependent personality disorder. Which goal is most appropriate for this client

using the problem solving process effectively

a nurse reviews assessment data for a client admitted to the mental health unit and notes that the client is experiencing anxiety b/c of a situational crisis. Which event could cause this type of crisis

loss of a job

a client on the mental health unit says to the evening nurse, "The staff on the day shift let me smoke two cigarettes. You only let me smoke one." Which response by the nurse is therapeutic

the policy is one cigarette. We'll follow the policy

a mental health nurse finds a client in the hospital day room self-inflicting cigarette burns. After removing the cigarette and attending to the burns, what is the nurse's next action

instituting one on one supervision

a phlebotomist prepares to draw blood from a client experiencing delusions. While in the lab, the client begins shouting, "you're all blood suckers. Get me out of here". Which response by the nurse is therapeutic

it must be scary to think others want to hurt you

a client with depression says, "My children hate me." Which response by the nurse is therapeutic

it sounds like you're having a difficult time with your children

a nurse receives a call from a client who states, "I'm going to kill myself, and I have a loaded gun in my lap". The nurse should first

keep the client talking and encourage her to express her feelings

as the nurse prepares a client for a CABG, the client asks, "will I be okay?" Which response by the nurse is therapeutic

let's talk about how you're feeling

a nurse assesses a client hospitalized with schizophrenia for whom risperidone has been prescribed. Which lab test result should the nurse check before administering the first dose of this med

liver function studies

buspirone hydrochloride is prescribed for a client with an anxiety disorder. The nurse, providing information to the client about the med, should tell the client that

mild dizziness and nervousness may occur

Lorazepam has been prescribed for a client for management of anxiety. Which finding in the client's history would indicate the nurse the need to confer with the healthcare provider before administering the medication?

narrow-angle glaucoma

a nurse is caring for a victim of sexual assault. The client's physical assessment is complete. The client's psychological reaction to the assault includes fear, confusion, disorganization, and restlessness. How should the nurse interpret these behaviors

normal reactions to a traumatic event

the wife of an alcoholic client begins attending Al-Anon groups three weeks ago. The nurse determines that the wife is benefiting from the groups when she states

now I realize that I didn't deserve the beatings my husband inflicted on me

a client with severe depression tells the nurse, "I'm feeling much better now." The client demonstrates increased interaction and energy levels. The nurse implements one-on-one supervision b/c the behavior indicates that the client

now has the energy to carry out a suicide plan

A nurse overhears a hospitalized client with mania telling another client, "I'm actually a journalist writing an article for a magazine-I'm just posing as a person with mental illness." How should the nurse respond

presenting the client with the actual situation

a nurse monitors a client in seclusion. The client calmly says to the nurse, "I'm no longer a threat to myself or others". The nurse interprets this statement as an indication that the client may be

ready to come out of seclusion

a client is hospitalized after falling asleep at the wheel of the car, hitting and killing a pedestrian crossing the street. The nurse caring for the client notes that the client is crying and upset. What is the appropriate reaction by the nurse

saying to the client. "I can see that you're crying. I'm here to talk to you"

a nurse assesses a new client hospitalized on the mental health unit. The client is experiencing negative thinking and says, "I'm doomed to failure." The nurse recognizes that the client's announcement indicates problems with

self-esteem

a nurse discovers a hospitalized client with depression wrapping long shreds of torn sheets around his neck. What is the priority nursing concern for this client

self-inflicted injury

a nurse is assigned to care for a client with a dx of catatonic stupor. When the nurse enters the client's room, the client is lying on the bed in a fetal position. What should the nurse do

sit beside the client in silence

a nurse develops a plan of care for a client with depression who has experienced a 24lb weight loss in the past 2 months. Which intervention should the nurse include in the plan of care

sitting with the client to make food and fluid choices from the menu

a nurse reviews the lab results of a client taking lithium. Which serum electrolyte value would the nurse identify as a precipitating factor for lithium toxicity

sodium 130

the parents of an 18 month old arrive at the ED with their unconscious child. Physical exam reveals bruises on the child's upper arms that resemble grip marks. Which nursing intervention is the priority

stabilizing the child's physical condition

a woman arrives at the ED accompanied by her husband, seeking care for cuts to her eye and multiple contusions. The client has been in the ED numerous times for similar injuries and the nurse suspects that the husband is inflicting the injuries. Which action should the nurse take

taking the client to a private area to conduct the interview

a psych nurse assists victims of a night club fire and their families. Which actions on the part of the nurse is the most important intervention in the immediate post disaster period

talking to people seeking assistance from the American Red Cross

a client with depression says to the nurse, "My child is dead and I don't want to live anymore." Which comment by the nurse is therapeutic

tell me more about how you're feeling

a client hospitalized in a mental health unit is restrained after becoming extremely violent. which finding indicates to the nurse that the client can be removed from the restraints

the client initiates no aggressive acts for 30 min after the release of two leg restraints

A nurse analyzes assessment findings in a client with physical injuries that are suspected by the staff of having been inflicted during family-related violence. Which factor should the nurse first consider

the client's vital signs

a client admitted to the mental health unit with depression is unclean, has body odor, and is inappropriately dressed. An accompanying family member is embarassed about the client's appearance. When planning care, it is most important for the client and family member to understand that

the nurse will help the client meet hygiene needs until the client is able to do so

a nurse cares for a severely depressed client who is mute. Which comment by the nurse to the client is approrpaite

there are many new pictures on the wall

a client, upset, says, "My ex-wife's now husband is being relocated to a job across the country, so now I'll only see my child on holidays and school vacations". Which response by the nurse is therapeutic

this must be very difficult for your child to move away from you, school and friends

a client says to the nurse, "even though my husband and I keep telling them we don't to have children, our parents are pressuring us to 'start a family'. What should we say to them?" Which of the following responses by the nurse is therapeutic

this must be very difficulty for both of you

a nurse prepares to care for a client with a dx of Tourette syndrome. The medical record indicates that the client experiences motor tics. Which finding would the nurse expect to note during assessment of this client

tongue protrusion

a client says, "I've had so many crying spells over the past several weeks. My doctor says it's probably depression." The nurse sees that the client is sitting slumped in the chair and that the client's clothing is baggy. Further assessment of this client should be focused on

weight loss

a client says to the nurse, "My cancer is going to shorten my life, so I'm making a will that leaves my money to charity.Do you think I can get into heaven that way?" Which response by the nurse is therapeutic

you feel that a charitable contribution will get you into heaven if your cancer ends your life?

a gay man is brought to the ED by the police. The client tells the nurse, "I was beaten up. I guess I just have to expect this kind of tx for the rest of my life." Which statement by the nurse is therapeutic

you feel that being beaten up goes along with being gay

a client says to the nurse, "My wife retired last year from a lucrative law practice and I'm really discouraged. I'll be working until I die, even though I helped pay for her education." Which response by the nurse is supportive

you sound very troubled by this

a nurse develops a plan of care for a client with a dx of PTSD. Which goal for the client is appropriate

reporting a decrease in nightmares

a nurse employed in a prison infirmary for a client recuperating from a stab wound. The client says, "You have beautiful eyes and you smell nice." Which response or action on the part of the nurse would be therapeutic

"I'm here to change your dressing, not discuss my eyes or how I smell"

a client says to the nurse, "I'm divorced and my children live in other parts of the country. They never visit or phone me. I feel so lonely. No one would notice if I were gone." The nurse should make which response to the client

"things seem very bleak to you right now. Are you thinking of harming yourself?"

a client says, "I have so much trouble caring for my husband's child from his first marriage. I resent the money we have to pay for child support bc we have to deprive my own child of things. How can I stop feeling this way?" Which response by the nurse is therapeutic?

have you shared your feelings with your husband

a young adult client says, "I just can't seem to stop snapping at my parents. I know they work hard to support me, but what do I do when they're so overbearing?" Which responses by the nurse is therapeutic

have you talked to your parents about your frustrations

A nurse works during the evening shift. Which actions should be performed for a client who will undergo electroconvulsive therapy (ECT) on the next day? Select all that apply. a) helping the client reduce anxiety about the procedure b) restricting visitors and limiting participation in unit activities c) discussing the risks and benefits of and alternatives to ECT with this client d) having the client shampoo and dries her hair, cleaning it of all hairspray and creams e) implementing NPO status for 12-16 hours before the procedure

a, d

a client tells the nurse, "I did my hair like my favorite math teacher wears hers. I hope I can be a good teacher, too." Which defense mechanism is the client using

identification

a client with depression says, "I always make mistakes. I never do anything right." Which response by the nurse is therapeutic

identifying recent accomplishments that demonstrate the client's abilities

A client prepares to attend an Alcoholics Anonymous meeting for the first time. Which step, the first in the 12-step program, should the nurse discuss with the client?

admitting to having a problem

a nurse develops a plan of care for a client in whom AIDS was recently diagnosed. The client is experiencing difficulty adjusting to the illness. Which interventions are appropriate for this client SATA a) assisting the client in verbalizing fears b) helping the client identify sources of hope c) monitoring the client for signs of self harm d) assisting the client with problem solving and decision making e) discouraging social networking to prevent the spread of infection

a, b, d

a nurse is providing medication instruction to a client who is starting disulfiram. Which statements by the client indicate that the client understands the information SATA a) it's important to take this med everyday b) painting my living room will be a good distraction c) I need to check the labels on OTC meds carfeully d) If I take this med and drink alcohol, I'll feel sick within 8 hours e) It's important to take this med when I have the urge to start drinking

a, c

a nurse develops a plan of care for a depressed client who is complaining of feelings of hopelessness and helplessness. Which interventions should the nurse include SATA a) assisting the client in identifying sources of hope b) frequently engaging in superficial social discussions c) giving the client time to respond during communication d) avoiding talking about serious issues that might further depress the client e) offering simple activities that provide the client an opportunity to be successful

a, c, e

amitriptyline hydrochloride has been prescribed for a client with depression and the nurse provided medication instructions. Which statements by the client indicate that the teaching was effective SATA a) It's important for me to avoid cheese products b) I can chew sugarless gum if my mouth feels dry c) This med will stop my depression immediately d) This med may make it hard for me to fall asleep e) I'm allowed to eat prunes every other day to prevent constipation

b, e

a nurse seeks to deescalate aggressive behavior by a client with schizophrenia. Which actions by the nurse are appropriate in this situation SATA a) standing close to the client b) being assertive with the client c) maintaining a nonaggressive posture d) notifying other staff of the client's behavior e) telling the client, "We may need to restrain you"

b-d

the lithium level in a client is 2.3. Which assessment finding would the nurse expect to note in the client based on this lab value

blurred vision

a nurse plans care for a client experiencing psychomotor agitation. Which activities would be appropriate for the client SATA a) playing chess b) reading magazines c) playing table tennis d) playing simple card games e) filling cups with ice for afternoon snacks

c, e

a nurse prepares equipment in the ECT suite for a client who will be arriving shortly for therapy. Which items are essential SATA a) thermometer b) bath blankets c) pulse-ox d) suction device e) ventilation equipment

c-e

a client with bipolar disorder has been hospitalized for 4 days. Today in group therapy the client offered helpful suggestions in regard to another client's problem. The nurse concludes that the client's behavior is representative of

improvement

a client with mania is placed in seclusion after an outburst of violent behavior that includes physically assaulting another client. As the client is secluded, the nurse should

inform the client, "You are being secluded to help you regain control of yourself"

a client hospitalized with schizophrenia says to the nurse, "Get your goat. Go out and vote. Don't be cut throat. Row your boat".How should the nurse document the client's behavior

clang associations

a nurse counsels a client with an alcohol disorder and the client's spouse. The spouse says, "I've covered up the drinking b/c I made a commitment to our marriage but now our children won't come visit." The nurse should refer the spouse to a support group for

codependents

a nurse assesses a client with early onset Alzheimer's disease. The nurse asks the client, "How was your weekend?" The client responds by saying, "It was great. I discussed war campaigns with the president and had dinner at the White House" Which defense mechanism is evident

confabulation

a client with a panic disorder has been medicated with alprazolam. Which assessment finding suggests that the client is experiencing a s/e of the med

confusion

a client experienced the sudden onset of blindness, but extensive testing revealed no organic reason that the client could not see. The nurse later learned that the blindness developed after the client witness a fire at a neighboring house in which the family of three died. Which problem should the nurse suspect

conversion disorder

the mother of a 3 y/o says, "My child hit his teddy bear after being scolded for picking the neighbor's flowers." Which defense mechanism was the child using

displacement

a client hospitalized with severe depression is withdrawn and exhibits poor motivation and concentration. Which activity should the nurse plan for this client

drawing

a hospitalized client with a dx of delirium often becomes disoriented and confused during the night. Which intervention does the nurse implement

ensuring a low-stimulation environment at night

a nurse plans care for a client with OCD. Which nursing intervention should receive priority

establishing a trusting nurse-client relationship

a nurse monitors a depressed adolescent who may be suicidal. Which behavior indicates that the client is at high risk for suicide

giving a cherished book of poems to another client

a nurse reviews the record of a client and notes that the client experiences flashbacks. Which of the following conditions is most often associated with flashbacks

hallucinogenic drug use

a client with a personality disorder will begin recreational therapy as a component of the tx plan. This tx modality is most helpful for clients who

have difficulty socializing