HESI-PN Mental Health
Laboratory work is prescribed for a client who has been experiencing delusions. When the laboratory technician approaches the client to obtain a specimen of the client's blood, the client begins to shout, "You're all vampires. Let me out of here!" The nurse present at the time should respond with which question or statement? 1."The technician is not going to hurt you but is going to help." 2."Are you fearful and think that others may want to hurt you?" 3."What makes you think that the technician wants to hurt you?" 4."The technician will leave and come back later for your blood."
"Are you fearful and think that others may want to hurt you?" Option 2 is the only option that recognizes the client's need. This response helps the client focus on the emotion underlying the delusion but does not argue with it. If the nurse attempts to change the client's mind, the delusion may, in fact, be even more strongly held. Options 1, 3, and 4 do not focus on the client's feelings.
The nurse is collecting data on a client who is actively hallucinating. Which nursing statement would be therapeutic at this time? 1."I know you feel 'they are out to get you,' but it's not true." 2."I can hear the voice, and she wants you to come to dinner." 3."Sometimes people hear things or voices others can't hear." 4."I talked to the voices you're hearing and they won't hurt you now."
"Sometimes people hear things or voices others can't hear." It is important for the nurse to reinforce reality with the client. Options 1, 2, and 4 do not reinforce reality but reinforce the hallucination that the voices are real.
Which client is most likely at risk to become a victim of elder abuse? 1.A 75-year-old man with moderate hypertension 2.A 68-year-old man with newly diagnosed cataracts 3.A 90-year-old woman with advanced Alzheimer's disease 4.A 70-year-old woman with early diagnosed Lyme disease
A 90-year-old woman with advanced Alzheimer's disease Elder abuse is widespread and occurs among all subgroups of the population. It includes physical and psychological abuse, the misuse of property, and the violation of rights. The person at highest risk of abuse is an elder with dementia that occurs with Alzheimer's disease.
The nurse is preparing a client for the termination phase of the nurse-client relationship. Which task should the nurse appropriately plan for during this phase? 1.Plan short-term goals. 2.Identify expected outcomes. 3.Assist with making appropriate referrals. 4.Assist with developing realistic solutions.
Assist with making appropriate referrals. Tasks of the termination phase include evaluating client performance, evaluating achievement of expected outcomes, evaluating future needs, making appropriate referrals, and dealing with the common behaviors associated with termination. Options 1, 2, and 4 identify the tasks of the working phase of the relationship.
The nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire, but despite the client's efforts, the neighbor died. Which action should the nurse take to enable the client to work through the meaning of the crisis? 1.Identifying the client's ability to function 2.Identifying the client's potential for self-harm 3.Inquiring about the client's feelings that may affect coping 4.Inquiring about the client's perception of the cause of the neighbor's death
Inquiring about the client's feelings that may affect coping The client must first deal with feelings and negative responses before the client is able to work through the meaning of the crisis. Option 3 pertains directly to the client's feelings. Options 1, 2, and 4 do not directly address the client's feelings.
Which data indicate to the nurse that a client is experiencing effective coping following the loss of a spouse? Select all that apply. 1.Looks at old snapshots of family 2.Constantly neglects personal grooming 3.Visits the spouse's grave once a month 4.Visits the senior citizens' center once a month 5.Prefers to spend time alone and avoids contact with others
Looking at old snapshots of family Visits the Spouse's grave once a month Visits the senior citizens' center once a month Coping mechanisms are behaviors that are used to decrease stress and anxiety. Visiting a spouse's grave, visiting the senior citizens' center, and looking at snapshots of the family are effective coping mechanisms. Neglecting grooming and preferring to spend time alone and avoiding contact with others are behaviors that identify ineffective coping of the grieving process.
The nurse is assigned to care for a client experiencing disturbed thought processes. The nurse is told that the client believes that their food is being poisoned. Which communication technique should the nurse plan to use to encourage the client to eat? 1.Open-ended questions and silence 2.Focusing on self-disclosure regarding food preferences 3.Stating the reasons that the client may not want to eat 4.Offering opinions about the necessity of adequate nutrition
Open-ended questions and silence Open-ended questions and silence are strategies used to encourage clients to discuss their problem. Options 3 and 4 do not encourage the client to express feelings. The nurse should not offer opinions and should not state the reasons, but should encourage the client to identify the reasons for their behavior. Option 2 is not a client-centered intervention.
A client is admitted to the psychiatric nursing unit. When collecting data from the client, the nurse notes that the client was admitted on an involuntary status. Based on this type of admission, which would the nurse expect to note? 1.The client presents a harm to self. 2.The client requested the admission. 3.The client consented to the admission. 4.The client provided written application to the facility for admission.
The client presents a harm to self. Involuntary admission is made without the client's consent. Involuntary admission is necessary when a person is a danger to self or others or is in need of psychiatric treatment or physical care. Options 2, 3, and 4 describe the process of voluntary admission.
The nurse is assisting with the data collection on a client admitted to the psychiatric unit. After review of the obtained data, the nurse should identify which as a priority concern? 1.The client's report of not eating or sleeping 2.The presence of bruises on the client's body 3.The client's report of self-destructive thoughts 4.The family member is disapproving of the treatment.
The client's report of self-destructive thoughts The client's thoughts are extremely important when verbalized. Self-destructive thoughts are the highest priority. Options 1, 2, and 4 will all affect the treatment of the client but are not of greatest importance at this time.
A client with delirium becomes agitated and confused at night. The best initial intervention by the nurse is which action? 1.Move the client next to the nurse's station. 2.Use a night light and turn off the television. 3.Keep the television and a soft light on during the night. 4.Play soft music during the night and maintain a well-lit room.
Use a night light and turn off the television. It is important to provide a consistent daily routine and a low-stimulation environment when the client is agitated and confused. Noise levels including a radio and television may add to the confusion and disorientation. Moving the client next to the nurses' station is not the initial intervention.
The psychiatric nurse is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? She is my best friend and is seen at your clinic every week." Which is the appropriate nursing response? 1."I cannot discuss any client situation with you." 2."I'm not supposed to discuss this, but because you are my neighbor, I can tell you that she is doing great!" 3."You may want to know about Carol, so you need to ask her yourself so you can get the story firsthand." 4."I'm not supposed to discuss this, but because you are my neighbor, I can tell you that she really has some problems!"
"I cannot discuss any client situation with you." The nurse is required to maintain confidentiality regarding clients and their care. Confidentiality is basic to the therapeutic relationship and is a client's right. Option 3 is correct in a sense, but it is a rather blunt statement. Both options 2 and 4 identify statements that do not maintain client confidentiality.
An intoxicated client is brought to the emergency department by local police. The client is told that the primary health care provider (PHCP) will be in to see the client in about 30 minutes. The client becomes very loud and offensive and wants to be seen by the PHCP immediately. The nurse assisting to care for the client should take which appropriate nursing intervention? 1.Watch the behavior escalate before intervening. 2.Attempt to talk with the client to de-escalate the behavior. 3.Offer to take the client to an examination room until he or she can be treated. 4.Inform the client that he or she will be asked to leave if the behavior continues.
Offer to take the client to an examination room until he or she can be treated. Safety of the client, other clients, and staff is of prime concern. Option 3 is in effect an isolation technique that allows for separation from others and provides for a less stimulating environment where the client can maintain dignity. When dealing with an impaired individual, trying to talk may be out of the question. Waiting to intervene could cause the client to become even more agitated and a threat to others. Option 4 would only further aggravate an already agitated individual.
A client is admitted to a psychiatric unit for treatment of a psychotic disorder. The client is at the locked exit door and is shouting, "Let me out! There's nothing wrong with me! I don't belong here!" The nurse identifies this behavior as which defense mechanism? 1.Denial 2.Projection 3.Regression 4.Rationalization
Denial Denial is the refusal to admit to a painful reality and is treated as if it does not exist. In projection, a person unconsciously rejects emotionally unacceptable features and attributes them to other people, objects, or situations. In regression, the client returns to an earlier, more comforting, although less mature, way of behaving. Rationalization is justifying the unacceptable attributes about oneself.
A client says to the nurse, "I'm going to die, and I wish my family would stop hoping for a 'cure'! I get so angry when they carry on like this! After all, I'm the one who's dying." Which therapeutic response should the nurse make to the client? 1."Have you shared your feelings with your family?" 2."I think we should talk more about your anger with your family." 3."You're feeling angry that your family continues to hope for you to be 'cured'?" 4."Well, it sounds like you're being pretty pessimistic. After all, years ago people died of pneumonia."
"You're feeling angry that your family continues to hope for you to be 'cured'?" Reflection is the therapeutic communication technique that redirects the client's feelings back to validate what the client is saying. In option 2, the nurse attempts to use focusing, but the attempt to discuss central issues is premature. In option 4, the nurse makes a judgment and is nontherapeutic in the one-on-one relationship. In option 1, the nurse is attempting to assess the client's ability to openly discuss feelings with family members. Although this may be appropriate, the timing is somewhat premature and closes off facilitation of the client's feelings.
The nurse observes that a client is psychotic, pacing, and agitated and is making aggressive gestures. The client's speech pattern is rapid, and the client's effect is belligerent. Based on these observations, which is the nurse's immediate priority of care? 1.Provide safety for the client and other clients on the unit. 2.Provide the clients on the unit with a sense of comfort and safety. 3.Assist the staff with caring for the client in a controlled environment. 4.Offer the client a less-stimulating area to calm down and gain control.
Provide safety for the client and other clients on the unit. Safety of the client and other clients is the priority. Option 1 is the only option that addresses the client and other clients' safety needs. Option 2 addresses other clients' needs. Option 3 is not client centered. Option 4 addresses the client's needs.
The nurse is caring for a client with a diagnosis of depression. The nurse monitors for signs of constipation and urinary retention, knowing that these problems are likely caused by which situation? 1.Poor dietary choices 2.Lack of exercise and poor diet 3.Inadequate dietary intake and dehydration 4.Psychomotor retardation and side effects of medication
Psychomotor retardation and side effects of medication In this situation, urinary retention is most likely caused by medications. Option 4 is the only option that addresses both constipation and urinary retention. Constipation can be related to inadequate food intake, lack of exercise, and poor diet.
The nurse in a psychiatric unit is assigned to care for a client admitted to the unit 2 days ago. During review of the client's record, the nurse notes that the admission was a voluntary one. Based on this type of admission, which would the nurse expect to note? 1.The client will be angry and will refuse care. 2.The client will participate in the treatment plan. 3.The client will be very resistant to treatment measures. 4.The client's family will be very resistant to treatment measures.
The client will participate in the treatment plan. Generally, voluntary admission is sought by the client or client's guardian. If the client seeks voluntary admission, the most likely expectation is that the client will participate in the treatment program. Options 1 and 3 are not likely for a client seeking voluntary admission. Option 4 is not centered on the individual client.
Following a group therapy session, a client approaches the nurse and verbalizes a need for seclusion because of uncontrollable feelings. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action? 1.Call the client's family. 2.Place the client in seclusion immediately. 3.Inform the client that seclusion has not been prescribed. 4.Get a written prescription from the primary health care provider (PHCP) and obtain an informed consent.
Get a written prescription from the primary health care provider (PHCP) and obtain an informed consent. A client may request to be secluded or restrained. Federal laws require the consent of the client unless an emergency situation exists in which an immediate risk to the client or others can be documented. The use of seclusion and restraint is permitted only with the written prescription of the PHCP, which must be reviewed and renewed every 24 hours, depending on state law requirements. It must also specify the type of restraint to be used.
The nurse is providing care for a client admitted to the hospital with a diagnosis of anxiety disorder. The nurse is talking with the client, and the client says, "I have a secret that I want to tell you. You won't tell anyone about it, will you?" Which is the appropriate nursing response? 1."No, I won't tell anyone." 2."I cannot promise to keep a secret." 3."If you tell me the secret, I will tell it to your doctor." 4."If you tell me the secret, I will need to document it in your record."
"I cannot promise to keep a secret." The nurse should never promise to keep a secret. Secrets are appropriate in a social relationship but not in a therapeutic one. The nurse needs to be honest with the client and tell the client that a promise cannot be made to keep the secret.
The nurse is preparing for the hospital discharge of a client with a history of command hallucinations to harm self or others. The nurse instructs the client about interventions for hallucinations and anxiety and determines that the client understands the interventions when the client makes which statement? 1."My medications won't make me anxious." 2."I'll go to a support group and talk so that I won't hurt anyone." 3."I won't get anxious or hear things if I get enough sleep and eat well." 4."I can call my therapist when I'm hallucinating so I can talk about my feelings and plans and not hurt anyone."
"I can call my therapist when I'm hallucinating so I can talk about my feelings and plans and not hurt anyone." There may be an increased risk for impulsive and/or aggressive behavior if a client is receiving command hallucinations to harm self or others. Talking about the auditory hallucinations can interfere with the subvocal muscular activity associated with a hallucination. Option 4 is a specific agreement to seek help and evidences self-responsible commitment and control over his or her own behavior.
The nurse enters a client's room, and the client immediately demands to be released from the hospital. During review of the client's record, the nurse notes that the client was admitted 2 days ago for the treatment of an anxiety disorder and that the admission was a voluntary one. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action? 1.Call the client's family. 2.Persuade the client to stay a few more days. 3.Contact the primary health care provider (PHCP). 4.Tell the client that discharge is not possible at this time.
Contact the primary health care provider (PHCP). Generally, voluntary admission is sought by the client or client's guardian. Voluntary clients have the right to demand and obtain release. The best nursing action is to contact the PHCP. Option 1 violates client confidentiality. Option 2 is not therapeutic or appropriate. Option 4 does not apply to a voluntary admission status.
The nurse in the mental health unit reviews the therapeutic and nontherapeutic communication techniques with a nursing student. Which are therapeutic communication techniques? Select all that apply. 1.Restating 2.Listening 3.Asking the client, "Why?" 4.Maintaining neutral responses 5.Giving advice, approval, or disapproval 6.Providing acknowledgment and feedback
Restating Listening Maintaining neutral responses Providing acknowledgement and feedback Some therapeutic communication techniques include listening, maintaining silence, maintaining neutral responses, using broad openings and open-ended questions, focusing and refocusing, restating, clarifying and validating, sharing perceptions, reflecting, providing acknowledgment and feedback, giving information and presenting reality, encouraging formulation of a plan of action, providing nonverbal encouragement, and summarizing. Asking why, giving advice, and approving or disapproving are nontherapeutic.
A client is admitted to the in-patient unit and is being considered for electroconvulsive therapy (ECT). The client appears calm, but the family is hypervigilant and anxious. The client's mother begins to cry and states, "My child's brain will be destroyed. How can the doctor do this?" The nurse should make which therapeutic response? 1."It sounds as though you need to speak to the psychiatrist." 2."Perhaps you'd like to see the ECT room and speak to the staff." 3."Your child has decided to have this treatment. You should be supportive of the decision." 4."It sounds as though you have some concerns about the ECT procedure. Why don't we sit down together and discuss any concerns you may have?"
"It sounds as though you have some concerns about the ECT procedure. Why don't we sit down together and discuss any concerns you may have?" The nurse needs to encourage the family and client to verbalize their fears and concerns. Option 4 is the only option that encourages verbalization. Options 1, 2, and 3 avoid dealing with the client or family concerns.
Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply. 1.Communicate expected behaviors to the client. 2.Follow through about the consequences of behavior in a nonpunitive manner. 3.Ensure that the client knows that he or she is not in charge of the nursing unit. 4.Assist the client with developing a means of setting limits on personal behavior. 5.Enforce rules and inform the client that he or she will not be allowed to attend therapy groups. 6.Be clear with the client regarding the consequences of exceeding limits set regarding behavior.
Communicate expected behaviors to the client. Follow through about the consequences of behavior in a nonpunitive manner. Assist the client with developing a means of setting limits on personal behavior. Be clear with the client regarding the consequences of exceeding limits set regarding behavior. Interventions for dealing with the client exhibiting manipulative behavior include setting clear, consistent, and enforceable limits on manipulative behaviors; being clear with the client regarding the consequences of exceeding limits set; following through with the consequences in a nonpunitive manner; and assisting the client with developing a means for setting limits on personal behaviors. Enforcing rules and informing the client that he or she will not be allowed to attend therapy groups are violations of a client's rights. Ensuring that the client knows that he or she is not in charge of the nursing unit is inappropriate; power struggles need to be avoided.
