HESI mental health.

. A nurse working on a mental health unit receives a community call from a person who is tearful and states, "I just feel so nervous all of the time. I don't know what to do about my problems. I haven't been able to sleep at night and have hardly eaten for the past 3 or 4 days." The nurse should initiate a referral based on which assessment? A Altered thought processes. B Moderate levels of anxiety. C Inadequate social support. D Altered health maintenance. .

B

. A young adult male client, diagnosed with paranoid schizophrenia, believes that world is trying poison him. What intervention should the nurse include in this client's plan of care? A Remind the client that his suspicions are not true. B Ask one nurse to spend time with the client daily. C Encourage the client to participate in group activities. D Assign the client to a room closest to the activity room. .

B

. On admission to a residential care facility, an elderly female client tells the nurse that she enjoys cooking, quilting, and watching television. Twenty-fours after admission, the nurse notes that the client is withdrawn and isolated. It is best for the nurse to encourage this client to become involved in which activity? A Clean the unit kitchen cabinets. B Participate in a group quilting project. C Watch television in the activity room. D Bake a cake for a resident's birthday.

B

. The nurse is assessing the parents of a nuclear family who are attending a support group for parents of adolescents. According to Erikson, these parents who are adapting to middle adulthood should exhibit which characteristic? A Loss of independence. B Increased self-understanding. C Isolation from society. D Development of intimate relationships.

B

. The nurse observes a client who is admitted to the mental health unit and identifies that the client is talking continuously, using words that rhyme but that have no context or relationship with one topic to the next in the conversation. This client's behavior and thought processes are consistent with which syndrome? A Dementia. B Depression. C Schizophrenia. D Chronic brain syndrome.

C

On admission, a highly anxious client is described as delusional. The nurse understands that delusions are most likely to occur with which class of disorder? A Neurotic. B Personality. C Anxiety. D. Psychotic

D

A client is admitted with a diagnosis of depression. The nurse knows that which characteristic is most indicative of depression? A Grandiose ideation. B Self-destructive thoughts. C Suspiciousness of others. D. A negative view of self and the future

D.

An 86-year-old female client with Alzheimer's disease is wandering the busy halls of the extended care facility and asks the nurse, "Where should I stand for the parade?" Which response is best for the nurse to provide? A "Anywhere you want to stand as long as you do not get hurt by those in the parade." B "You are confused because of all the activity in the hall. There is no parade." C "Let's go back to the activity room and see what is going on in there." D "Remember I told you that this is a nursing home and I am your nurse."

C.

. The nurse should hold the next scheduled dose of a client's haloperidol (Haldol) based on which assessment finding(s)? A Dizziness when standing. B Shuffling gait and hand tremors. C Urinary retention. D Fever of 102 F.

D

. A male client is admitted to a mental health unit on Friday afternoon and is very upset on Sunday because he has not had the opportunity to talk with the healthcare provider. Which response is best for the nurse to provide this client? A "Let me call and leave a message for your healthcare provider." B "The healthcare provider should be here on Monday morning." C "How can I help answer your questions?" D "What concerns do you have at this time?"

A

The nurse is preparing to administer phenelzine sulfate (Nardil) to a client on the psychiatric unit. Which complaint related to administration of this drug would the nurse expect this client to make? A "My mouth feels like cotton." Correct B "That stuff gives me indigestion." C "This pill gives me diarrhea." D "My urine looks pink."

A

. A female client with obsessive-compulsive disorder (OCD) is describing her obsessions and compulsions and asks the nurse why these make her feel safer. What information should the nurse include in this client's teaching plan? (Select all that apply.) A Compulsions relieve anxiety. B Anxiety is the key reason for OCD. C Obsessions cause compulsions. D Obsessive thoughts are linked to levels of neurochemicals. E Antidepressant medications increase serotonin levels.

ABDE

The nurse should include which interventions in the plan of care for a severely depressed client with neurovegetative symptoms? (Select all that apply.) A Permit rest periods as needed. B Speaking slowly and simply. C Place the client on suicide precautions. D Allow the client extra time to complete tasks. E Observe and encourage food and fluid intake. F Encourage mild exercise and short walks on the unit

ABDEF

. An adult male client who was admitted to the mental health unit yesterday tells the nurse that microchips were planted in his head for military surveillance of his every move. Which response is best for the nurse to provide? A "You are in the hospital, and I am the nurse caring for you." B "It must be difficult for you to control your anxious feelings." C "Go to occupational therapy and start a project." D "You are not in a war area now; this is the United States."

C

A male client is admitted to the psychiatric unit with a medical diagnosis of paranoid schizophrenia. During the admission procedure, the client looks up and states, "No, it's not MY fault. You can't blame me. I didn't kill him, you did." What action is best for the nurse to take? A Reassure the client by telling him that his fear of the admission procedure is to be expected. B Tell the client that no one is accusing him of murder and remind him that the hospital is a safe place. C Assess the content of the hallucinations by asking the client what he is hearing. D Ignore the behavior and make no response at all to his delusional statements.

C

A client on the psychiatric unit appears to imitate a certain nurse on the unit. The client seeks out this particular nurse and imitates the nurse's mannerisms. The nurse knows that the client is using which defense mechanism? A Sublimation. B Identification. C Introjection. D Repression.

B

A child is brought to the emergency room with a broken arm. Because of other injuries, the nurse suspects the child may be a victim of abuse. When the nurse tries to give the child an injection, the child's mother becomes very loud and shouts, "I won't leave my son! Don't you touch him! You'll hurt my child!" What is the best interpretation of the mother's statements? The mother is A regressing to an earlier behavior pattern. B sublimating her anger. C projecting her feelings onto the nurse. D suppressing her fear.

C

. An anxious client expressing a fear of people and open places is admitted to the psychiatric unit. What is the most effective way for the nurse to assist this client? A Plan an outing within the first week of admission. B Distract her whenever she expresses her discomfort about being with others. C Confront her fears and discuss the possible causes of these fears. D. Accompany her outside for an increasing amount of time each day

D

. A 19-year-old female client with a diagnosis of anorexia nervosa wants to help serve dinner trays to other clients on a psychiatric unit. What action should the nurse take? A Encourage the client's self-motivation by asking her to pass trays for the rest of the week. B Provide an additional challenge by asking the client to help feed the older clients. C Suggest another way for this client to participate in the unit's activities. D Tell the client that hospital guidelines allow only staff to pass the trays.

C

. 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 Diphenhydramine (Benadryl). C Chlordiazepoxide (Librium). D Isocarboxazid (Marplan).

C

. 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 Excessive CNS stimulation will be reduced. D Client's level of consciousness will increase.

C

. A nurse working in the emergency room of a children's hospital admits a child whose injuries could have resulted from abuse. Which statement most accurately describes the nurse's responsibility in cases of suspected child abuse? A The nurse should obtain objective data such as x-rays before reporting suspicions to the authorities. B The nurse should confirm any suspicions of child abuse with the healthcare provider before reporting to the authorities. C The nurse should report any case of suspected child abuse to the nurse in charge. D The nurse should note in the client's record any suspicions of child abuse so that a history of such suspicions can be tracked.

C

. The charge nurse is collaborating with the nursing staff about the plan of care for a client who is very depressed. What is the most important intervention to implement during the first 48 hours after the client's admission to the unit? A Monitor appetite and observe intake at meals. B Maintain safety in the client's milieu. C Provide ongoing, supportive contact. D Encourage participation in activities. .

B

The wife of a male client recently diagnosed with schizophrenia asks the nurse, "What exactly is schizophrenia? Is my husband all right?" Which response is best for the nurse to provide to this family member? A "It sounds like you're worried about your husband. Let's sit down and talk." B "It is a chemical imbalance in the brain that causes disorganized thinking." C "Your husband will be just fine if he takes his medications regularly." D "I think you should talk to your husband's psychologist about this question."

B

. A client with bipolar disorder on the mental health unit becomes loud, and shouts at one of the nurses, "You fat tub of lard! Get something done around here!" What is the best initial action for the nurse to take? A Have the orderly escort the client to his room. B Tell the client his healthcare provider will be notified if he continues to be verbally abusive. C Redirect the client's energy by asking him to tidy the recreation room. D Call the healthcare provider to obtain a prescription for a sedative.

C

. A woman arrives in the Emergency Center and tells the nurse she thinks she has been raped. The client is sobbing and expresses disbelief that a rape could happen because the man is her best friend. After acknowledging the client's fear and anxiety, how should the nurse respond? A "I would be very upset and mad if my best friend did that to me." B "You must feel betrayed, but maybe you might have led him on?" C "Rape is not limited to strangers and frequently occurs by someone who is known to the victim." D "This does not sound like rape. Did you change your mind about having sex after the fact?"

C

Over a period of several weeks, one male participant of a socialization group at a community day care center for the elderly monopolizes most of the group's time and interrupts others when they are talking. What is the best action for the nurse to take in this situation? A Talk to the client outside the group about his behavior during group meetings. B Remind the client to allow others in the group a chance to talk. C Allow the group to handle the problem. Correct D Ask the client to join another group.

C

. The nurse is taking a history for a female client who is requesting a routine female exam. Which assessment finding requires follow-up? A Menstruation onset at age 9. B Contraceptive method includes condoms only. C Menstrual cycle occurs every 35 days. D "Black-out" after one drink last night on a date.

D

. The nurse is assessing a client's intelligence. Which factor should the nurse remember during this part of the mental status exam? A Acute psychiatric illnesses impair intelligence. B Intelligence is influenced by social and cultural beliefs. C Poor concentration skills suggests limited intelligence. D The inability to think abstractly indicates limited intelligence. .

B

. When preparing a teaching plan for a client who is to be discharged with a prescription for lithium carbonate (Lithonate), it is most important for the nurse to include which instruction? A "It may take 3 to 4 weeks to achieve therapeutic effects." B "Keep your dietary salt intake consistent." C "Avoid eating aged cheese and chicken liver." D "Eat foods high in fiber such as whole grain breads."

B

1. At the first meeting of a group of older adults at a daycare center for the elderly, the nurse asks one of the members what kinds of things she would like to do with the group. The older woman shrugs her shoulders and says, "You tell me, you're the leader." What is the best response for the nurse to make? A "Yes, I am the leader today. Would you like to be the leader tomorrow?" B "Yes, I will be leading this group. What would you like to accomplish during this time?" C "Yes, I have been assigned to be the leader of this group. I will be here for the next six weeks." D "Yes, I am the leader. You seem angry about not being the leader yourself."

B

A 46-year-old female client has been on antipsychotic neuroleptic medication for the past three days. She has had a decrease in psychotic behavior and appears to be responding well to the medication. On the fourth day, the client's blood pressure increases, she becomes pale and febrile, and demonstrates muscular rigidity. Which action will the nurse initiate? A Place the client on seizure precautions and monitor carefully. B Immediately transfer the client to ICU. C Describe the symptoms to the charge nurse and record on the client's chart. D No action is required at this time as these are known side effects of such drugs.

B

. The nurse is planning care for a 32-year-old male client diagnosed with HIV infection who has a history of chronic depression. Recently, the client's viral load has begun to increase rather than decrease despite his adherence to the HIV drug regimen. What should the nurse do first while taking the client's history upon admission to the hospital? A Determine if the client attends a support group weekly. B Hold all antidepressant medications until further notice. C Ask the client if he takes St. John's Wort routinely. D Have the client describe any recent changes in mood.

C

. A 27-year-old female client is admitted to the psychiatric hospital with a diagnosis of bipolar disorder, manic phase. She is demanding and active. Which intervention should the nurse include in this client's plan of care? A Schedule her to attend various group activities. B Reinforce her ability to make her own decisions. C Encourage her to identify feelings of anger. D Provide a structured environment with little stimuli.

D

. A female client refuses to take an oral hypoglycemic agent because she believes that the drug is being administered as part of an elaborate plan by the Mafia to harm her. Which nursing intervention is most important to include in this client's plan of care? A Reassure the client that no one will harm her while she is in the hospital. B Ask the healthcare provider to give the client the medication. C Explain that the diabetic medication is important to take. D Reassess client's mental status for thought processes and content. .

D

. A female client with depression attends group and states that she sometimes misses her medication appointments because she feels very anxious about riding the bus. Which statement is the nurse's best response? A "Can your case manager take you to your appointments?" B "Take your medication for anxiety before you ride the bus." C "Let's talk about what happens when you feel very anxious." D "What are some ways that you can cope with your anxiety?"

D

. The nurse plans to help an 18-year-old female intellectually disabled client ambulate the first postoperative day after an appendectomy. When the nurse tells the client it is time to get out of bed, the client becomes angry and tells the nurse, "Get out of here! I'll get up when I'm ready!" Which response is best for the nurse to make? A "Your healthcare provider has prescribed ambulation on the first postoperative day." B "You must ambulate to avoid complications which could cause more discomfort than ambulating." C "I know how you feel. You're angry about having to ambulate, but this will help you get well." D "I'll be back in 30 minutes to help you get out of bed and walk around the room."

D

. Which diet selection by a client who is depressed and taking the MAO inhibitor tranylcypromine sulfate (Parnate) 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 a soft drink. D. Roast beef, baked potato with butter, and iced tea.

D

. Which statement about contemporary mental health nursing practice is accurate? A There is one approved theoretical framework for psychiatric nursing practice. B Psychiatric nursing has yet to be recognized as a core mental health discipline. C Contemporary practice of psychiatric nursing is primarily focused on inpatient care. The psychiatric nursing client may be an individual, family, group, organization, or community

D

A client, who is on a 30-day commitment to a drug rehabilitation unit, asks the nurse if he can go for a walk on the grounds of the treatment center. When he is told that his privileges do not include walking on the grounds, the client becomes verbally abusive. Which approach will the nurse take? A Call a staff member to escort the client to his room. B Tell the client to talk to his healthcare provider about his privileges. C Remind the client of the unit rules. Ignore the client's inappropriate behavior.

D

A 25-year-old female client has been particularly restless and the nurse finds her trying to leave the psychiatric unit. She tells the nurse, "Please let me go! I must leave because the secret police are after me." Which response is best for the nurse to make? A "No one is after you, you're safe here." B "You'll feel better after you have rested." C "I know you must feel lonely and frightened." "Come with me to your room and I will sit with you."

D.

. A 35-year-old male client who has been hospitalized for two weeks for chronic paranoia continues to state that someone is trying to steal his clothing. The most appropriate action for the nurse to take is to A encourage the client to actively participate in assigned activities on the unit. B place a lock on the client's closet. C ignore the client's paranoid ideation to extinguish these behaviors. D explain to the client that his suspicions are false.

A

. A 38-year-old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her, she refuses to eat and tells the nurse, "I know you are trying to poison me with that food." Which response would be most appropriate for the nurse to make? A "I'll leave your tray here. I am available if you need anything else." B "You're not being poisoned. Why do you think someone is trying to poison you?" C "No one on this unit has ever died from poisoning. You're safe here." D "I will talk to your healthcare provider about the possibility of changing your diet."

A.

Physical examination of a 6-year-old reveals several bite marks in various locations on his body. X-ray examination reveals healed fractures of the ribs. The mother tells the nurse that her child is always having accidents. Which initial response by the nurse is most appropriate? A "I need to inform the healthcare provider about your child's tendency to be accident prone." B "Tell me more specifically about your child's accidents." C "I must report these injuries to the authorities because they do not seem accidental." D "Boys this age always seem to require more supervision and can be quite accident prone."

B

The nurse is planning the care for a 32-year-old male client with acute depression. Which nursing intervention would be best in helping this client deal with his depression? A Ensure that the client's day is filled with group activities. B Assist the client in exploring feelings of shame, anger, and guilt. C Allow the client to initiate and determine activities of daily living. D Encourage the client to explore the rationale for his depression.

B

. A 35-year-old male client on the psychiatric unit of a general hospital believes that someone is trying to poison him. The nurse understands that a client's delusions are most likely related to his A early childhood experiences involving authority issues. B anger about being hospitalized. C low self-esteem. D phobic fear of food.

C

. A 22-year-old male client is admitted to the emergency center following a suicide attempt. His records reveal that this is his third suicide attempt in the past two years. He is conscious, but does not respond to verbal commands for treatment. Which assessment finding should prompt the nurse to prepare the client for gastric lavage? A He ingested the drug 3 hours prior to admission to the emergency center. B The family reports that he took an entire bottle of acetaminophen (Tylenol). C He is unresponsive to instructions and is unable to cooperate with emetic therapy. D Those with repeated suicide attempts desire punishment to relieve their guilt.

C>

. A client who is diagnosed with schizophrenia is admitted to the hospital. The nurse assesses the client's mental status. Which assessment finding is most characteristic of a client with schizophrenia? A Mood swings. B Extreme sadness. C Manipulative behavior. D. Flat affect

D

. A 45-year-old male client tells the nurse that he used to believe that he was Jesus Christ, but now he knows he is not. Which response is best for the nurse to make? A "Did you really believe you were Jesus Christ?" B "I think you're getting well." C "Others have had similar thoughts when under stress." "Why did you think you were Jesus Christ?"

c

. A 65-year-old female client complains to the nurse that recently she has been hearing voices. What question should the nurse ask this client first? A "Do you have problems with hallucinations?" B "Are you ever alone when you hear the voices?" C "Has anyone in your family had hearing problems?" D "Do you see things that others cannot see?"

B

. A client who is being treated with lithium carbonate for bipolar disorder develops diarrhea, vomiting, and drowsiness. What action should the nurse take? A Notify the healthcare provider immediately and prepare for administration of an antidote. B Notify the healthcare provider of the symptoms prior to the next administration of the drug. C Record the symptoms as normal side effects and continue administration of the prescribed dosage. D Hold the medication and refuse to administer additional amounts of the drug.

B

. A male client is admitted to the mental health unit because he was feeling depressed about the loss of his wife and job. The client has a history of alcohol dependency and admits that he was drinking alcohol 12 hours ago. Vital signs are: temperature, 100 F, pulse 100, and BP 142/100. The nurse plans to give the client lorazepam (Ativan) based on which priority nursing diagnosis? A Risk for injury related to suicidal ideation. B Risk for injury related to alcohol detoxification. C Knowledge deficit related to ineffective coping. D Health seeking behaviors related to personal crisis.

B

. A male client with mental illness and substance dependency tells the mental health nurse that he has started using illegal drugs again and wants to seek treatment. Since he has a dual diagnosis, which person is best for the nurse to refer this client to first? A The emergency room nurse. B His case manager. C The clinic healthcare provider. D His support group sponsor.

B

. The community health nurse talks to a male client who has bipolar disorder. The client explains that he sleeps 4 to 5 hours a night and is working with his partner to start two new businesses and build an empire. The client stopped taking his medications several days ago. What nursing problem has the highest priority? A Excessive work activity. B Decreased need for sleep. C Medication management. D Inflated self-esteem.

C

. The nurse is conducting discharge teaching for a client with schizophrenia who plans to live in a group home. Which statement is most indicative of the need for careful follow-up after discharge? A "Crickets are a good source of protein." B "I have not heard any voices for a week." C "Only my belief in God can help me." D "Sometimes I have a hard time sitting still."

C

A 45-year-old female client is admitted to the psychiatric unit for evaluation. Her husband states that she has been reluctant to leave home for the last six months. The client has not gone to work for a month and has been terminated from her job. She has not left the house since that time. This client is displaying symptoms of what condition? A Claustrophobia. B Acrophobia. C Agoraphobia. D Post-traumatic stress disorder.

C.

. A male client with schizophrenia tells the nurse that the voices he hears are saying, "You must kill yourself." To assist the client in coping with these thoughts, which response is best for the nurse to provide? A "Tell yourself that the voices are unreasonable." B "Exercise when you hear the voices." C "Talk to someone when you hear the voices." D "The voices aren't real, so ignore them."

A

. A 72-year-old female client is admitted to the psychiatric unit with a diagnosis of major depression. Which statement by the client should be of greatest concern to the nurse and require further assessment? A "I will die if my cat dies." Correct B "I don't feel like eating this morning." C "I just went to my friend's funeral." D "Don't you have more important things to do?"

A

. A homeless person who is in the manic phase of bipolar disorder is admitted to the mental health unit. Which laboratory finding obtained on admission is most important for the nurse to report to the healthcare provider? A Decreased thyroid stimulating hormone level. B Elevated liver function profile. C Increased white blood cell count. D Decreased hematocrit and hemoglobin levels.

A

. The nurse is planning discharge for a male client with schizophrenia. The client insists that he is returning to his apartment, although the healthcare provider informed him that he will be moving to a boarding home. What is the most important nursing diagnosis for discharge planning? A Ineffective denial related to situational anxiety. B Ineffective coping related to inadequate support. C Social isolation related to difficult interactions. D Self-care deficit related to cognitive impairment. .

A

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 A dissociative disorder. B obsessive-compulsive disorder. C panic disorder. D post-traumatic stress syndrome.

A

. A 30-year-old sales manager tells the nurse, "I am thinking about a job change. I don't feel like I am living up to my potential." Which of Maslow's developmental stages is the sales manager attempting to achieve? A Self-Actualization. B Loving and Belonging. C Basic Needs. D Safety and Security.

A.

. A client who has been admitted to the psychiatric unit tells the nurse, "My problems are so bad that no one can help me." Which response is best for the nurse to make? A "How can I help?" B "Things probably aren't as bad as they seem right now." C "Let's talk about what is right with your life." D "I hear how miserable you are, but things will get better soon."

A.

. A male adolescent is admitted with bipolar disorder after being released from jail for assault with a deadly weapon. When the nurse asks the teen to identify his reason for the assault, he replies, "Because he made me mad!" Which goal is best for the nurse to include in the client's plan of care? The client will A outline methods for managing anger. B control impulsive actions toward self and others. C verbalize feelings when anger occurs. D recognize consequences for behaviors exhibited.

B

. An elderly female client with advanced dementia is admitted to the hospital with a fractured hip. The client repeatedly tells the staff, "Take me home. I want my Mommy." Which response is best for the nurse to provide? A Orient the client to the time, place, and person. B Tell the client that the nurse is there and will help her. C Remind the client that her mother is no longer living. D Explain the seriousness of her injury and need for hospitalization.

B

A 40-year-old male client diagnosed with schizophrenia and alcohol dependence has not had any visitors or phone calls since admission. He reports he has no family that cares about him and was living on the streets prior to this admission. According to Erikson's theory of psychosocial development, which stage is the client in at this time? A Isolation. B Stagnation. C Despair. D Role confusion.

B

. Within several days of hospitalization, a client is repeatedly washing the top of the same table. Which initial intervention is best for the nurse to implement to help the client cope with anxiety related to this behavior? A Administer a prescribed PRN antianxiety medication. B Assist the client to identify stimuli that precipitates the ritualistic activity. C Allow time for the ritualistic behavior, then redirect the client to other activities. D Teach the client relaxation and thought stopping techniques. .

C