HESI Mental Health Remediation questions

The nurse is training a new team member. Which explanation best promotes effective communication when discussing group process and group content?

Content includes the clients' words, and group process is how the clients communicate.

Diphenhydramine is available as 100 mg/mL. The ordered dose is 75 mg IM. How many mL should the nurse administer? (Enter numerical value only. If rounding is necessary, round to the hundredth.)

D/H x Q = X75 mg divided by 100 mg x 1mL = 0.75 mL

Which thought process describes the client's inability to leave his apartment because he thinks someone is waiting to kill him?

Delusions.

The nurse understands that the purpose of the urine drug screen is to assess the client for what important information?

Detection of substances that may have caused the client's delusions and/or hallucinations.

What information is most important in determining a plan of care for post-traumatic stress syndrome for this client?

Her access to formal and informal social support.

Which lab results from the urinalysis can the nurse expect to be related to the client's 10-pound weight loss in the past 2 weeks? (Select all that apply. One, some, or all options may be correct.)

Positive ketones. Increased urine specific gravity.

Which nursing problem is best to include in the initial care plan?

Sensory-perceptual alteration related to withdrawal into self.

When the client explains that someone has been following him and is waiting outside the door of the ED, how should the nurse respond?

State how he must be concerned and assure him he will be safe there.

Which routine admission order should the nurse question?

Acetaminophen as needed.

Interventions for a client experiencing hallucinations upon admission should occur in a sequence. Which interventions are most important to be include in the client's initial plan of care? (Select all that apply. One, some, or all options may be correct.)

Acknowledge that it appears the client is hearing voices. Ask the client to verbalize what the voices are saying. Assess the content of the hallucinations message.

Which interventions should the nurse implement? (Select all that apply.)

Administer lorazepam 2 mg PO. Reassess vital signs in 2 hours. Provide an antiemetic.

The nurse has completed the assessment and has infromation to create a plan of care for client. Before stepping outside the room, the nurse explains to client that the healthcare provider will perform an examination but that the nurse will return afterward to speak with client again. The nurse exits the room and meets with the healthcare provider. What is the best way for the nurse to communicate client's history of violence with the healthcare provider?

After asking permission from client to inform the healthcare provider of the abuse, give a thorough report of the assessment findings.

Which is the best reason for the nurse to screen this client for intimate partner violence?

All women of childbearing age should be screened for intimate partner violence.

After the content of the voices are assessed, which interventions should the nurse implement? (Select all that apply. One, some, or all options may be correct.)

Ask the client how the voices make them feel. Instruct the client to utilize distractions to deal with hallucinations.

When the client looks around the room and mumbles to himself, how should the nurse respond?

Ask the client if they are hearing voices.

The client tells the nurse that she is not sure whether she will go back or not. Today, she intends to stay at the shelter, but she says she does not know what she will do tomorrow or the next day. She is attempting to take things one day at a time. Which of the following is the most appropriate action to take next based on the principles of bioethics?

Based on autonomy, the nurse should respect the client's decision to stay or leave.

The nurse observes the client looking to the corner of the room and mumbling to himself. Which intervention is most important for the nurse to make sure is in the client's plan of care?

Begin a sequence of interventions to address the client's hallucinations.

How might living in a domestic violence shelter act as an obstacle for recovery from post-traumatic stress syndrome?

Being away from familiar people, places, and routines may make coping more difficult. Living with a large number of strangers may cause overstimulation. Following house rules in the shelter may feel similar to the controlling nature of the abusive relationship.

Based on established and approved facility protocol orders, which medication is the nurse able to give to immediately relieve the muscle spasms in the client's neck and jaw?

Diphenhydramine IM.

Which response by the nurse is accurate?

Disulfiram inhibits absorption of alcohol.

Which question should the nurse ask in order to determine whether or not the client is able to return to a precrisis level of functioning?

Do you have support and people who can help you?

What neurotransmitter is targeted by haloperidol?

Dopamine.

Since the client is also experiencing delusions, what action is most important for the nurse to take to address the client's delusions?

Encourage the client to verbalize the meaning of the delusions.

Which response from the client indicates that the haloperidol has been effective?

Experiences fewer hallucinations.

The client is questioning the nurse about taking another pill. Which nursing intervention best promotes effective communication?

Explain that this pill is to help prevent the muscle spasms in neck and jaw.

Which action should the nurse take?

Explain to the UAP, away from the client, that initial client teaching must be performed by the nurse.

What is the best thing for the nurse to say in response to client wanting to return to her husband?

Express concerned about the client's safety if returning to a home situation that could result in of being injured or killed.

Which is not a symptom that the nurse would expect to see in a client with post-traumatic stress syndrome?

Feeling things more deeply than usual.

What risk factors for depression and anxiety are evident in the client's health history?

Female gender and history of physical abuse.

Two weeks after the initial visit, client returns with her two children. She tells the nurse that she is still living in the shelter and that many of the children there are sick with cold symptoms. Both of her children have congestion and a cough, but her oldest child has been wheezing. The healthcare provider prescribes albuterol 0.1 mg/kg. The child weighs 48 pounds. How many mg of albuterol should the nurse administer?

First convert pounds to kilograms (48 lbs = 22 kg). Then multiply by 0.1 (22 x 0.1=2.2). 2.2 mg

What action should the nurse take next?

Further assess the client's drinking behaviors.

What is a goal of being in this activity group?

Gain self-acceptance and express feelings.

Which assessment data are the best indicators of the potential for violence? (Select all that apply. One, some, or all options may be correct.)

Gender and age. Past suicide attempts. History of violence. Medication noncompliance.

The client admits that the voices he hears have been getting louder over the past couple of weeks. Which nursing intervention best promotes effective communication?

Have the client repeat what he thinks the voices are saying.

What is the first question that the nurse should ask?

Have you ever thought that you should cut down on your drinking?

Which products are acceptable for the client to use? (Select all that apply.)

Ibuprofen. Petroleum jelly.

The healthcare provider leaves the room after a consultation with the client. The nurse notes on the chart that the HCP diagnosis noted is Post-Traumatic Stress Disorder. The healthcare provider has prescribed paroxetine 20 mg per day by mouth and a referral to see a counselor. The nurse goes back into the room to talk about the plan of care and provide education on the prescription. First, the nurse wants to help client think of strategies to cope with the trauma and set some goals for the first few weeks after the visit.What would be an effective coping mechanism for dealing with post-traumatic stress for this client?

Identify and use a coping mechanism that she used and was effective when she was diagnosed with postpartum depression.

Which nursing intervention is most important to implement before disulfiram therapy?

If applicable per hospital policy, obtain the client's written consent to comply with instructions.

Which lab results indicate to the nurse the client probably has liver disease?

Increased aspartate aminotransferase (AST).

What mechanism of action accounts for symptoms of alcohol withdrawal delirium?

Increased dopamine.

While the healthcare provider is in the room, the nurse goes to the desk to write down a plan of care. While working, the nurse notices client's two children in the waiting area. The 6-year-old is sitting quietly next to the advocate. The child is rocking slightly in the chair and seems preoccupied. The 4-year-old is playing with another young child who is accompanied by a parent. The nurse hears the advocate tell the 4-year-old several times, "No hitting! We don't hit!" As the nurse develops a plan of care for client the nurse also begins to think about client's children and how they might be included in the plan of care. Which of the following is true about the affects of intimate partner violence on children?

Intimate partner violence can cause emotional problems in the child even if the child has not seen or heard the violence happening.

Which assessment finding warrants immediate intervention by the nurse?

Involuntary muscle contractions.

Which assessment data provides evidence that the client can be involuntarily committed to the hospital, if he insists on leaving?

Losing 10 pounds in 2 weeks.

What are the advantages for prescribing the atypical antipsychotic, olanzapine? (Select all that apply. One, some, or all options may be correct.)

Lower incidence of extrapyramidal symptoms (EPSEs). Rapid onset. Acute and maintenance therapy.

What are some ways to decrease the effects of the large changes on the children while they are in the shelter?

Maintain normalcy by keeping to family rituals as much as possible.

Which nursing action is appropriate for this request?

Obtain a order from the HCP to return medications.

While working on the care plan and observing the children, the nurse begins to feel emotional and angry. The nurse thinks that it is not fair to the children to be subjected to violence in the home. At first the nurse is angry at client's husband for the violence, and then becomes angry at the client for what has been a bad relationship decision. The nurse realizes that the community health center does not have a standard way of addressing potential negative feelings related to hearing about trauma from clients even though the staff members at the center frequently interact with women from the domestic violence shelter and many people who work or volunteer there.What should the nurse do as soon as negative emotions toward the client are realized?

Perform a self-assessment to determine the source of the feelings so that the nurse can address them before returning to speak with the client.

Which goal is most important for alcohol detoxification?

Physiologic stabilization.

What is the nurse most concerned about for this client, knowing her history of depression and intimate partner violence?

Possibility of suicide or self-harm.

What is the therapeutic action of benzodiazepines?

Potentiate effects of GABA.

Based on client's experiences of physical and sexual abuse and her symptoms found during the assessment, the nurse realizes that the priority nursing problem relates to possible post-traumatic stress syndrome since the client has been subjected to multiple instances of abuse. The nurse is ready to begin a plan of care for the client. Which is the most important piece of information that the nurse needs at this point to address for post-traumatic stress syndrome?

Previous history of abuse in childhood and adulthood.

What activity should the nurse suggest to the nurse's supervisor to help the nurses and other staff at the community health center deal with the emotional issues of interacting with traumatized clients in the future?

Provide a venue for talking about feelings related to interacting with traumatized clients while protecting the client's privacy.

What is it most important intervention for the nurse to perform before discharging the client?

Re-evaluate thoughts of harm to self or others.

What is the most important benefit the client can receive from his attendance at the community meeting?

Reality orientation.

What is the rationale for giving thiamine (B1) and a multivitamin?

Reduce the risk of Wernicke's disease.

While teaching the client about the anticholinergic side effects related to benztrophine, which intervention is most important for the nurse to ensure is include in the client's plan of care? (Select all that apply. One, some, or all options may be correct.)

Report urinary retention or feeling that the bladder does not empty. Relay any feeling of heart palpations.

Which is the most important consideration for discharge planning?

Resources available to the client after discharge.

Which priority nursing problems should be addressed within 72 hours of admission? (Select all that apply.)

Risk for injury. Altered nutrition. Risk for withdrawal.

Which are ramifications of drinking alcohol while taking disulfiram? (Select all that apply.)

Severe headache. Nausea and vomiting. Chest pain.

Based on the history of violence, which physical health conditions would the nurse expect the healthcare provider to screen for?

Sexually transmitted disease due to forced sex.

What other factors may affect client's risk for being murdered by her husband?

She will have a higher risk of being murdered if she believes he is capable of killing her.

Which medications should the nurse anticipate giving the client after getting orders from the healthcare provider? (Select all that apply. One, some, or all options may be correct.)

Short-acting anxiolytic (benzodiazepines). Antipsychotic medication.

After discussing the possibility of client returning to her husband, the nurse knows that the most important intervention that can be done immediately is to create a safety plan. What would not be an appropriate item to include on a safety plan?

Shredding important documents with personal information.

What does the nurse know about client's level of danger, based on the strangulation incident?

Strangulation is an indication that her risk of being murdered by her husband is high.

What is the most important part of this admission process?

Take away the client's cigarettes and lighter.

Which action should the nurse implement first?

Take the client's blood pressure while he is sitting and standing.

How should the nurse assess the children for post-traumatic stress syndrome?

The assessment should include their exposure to a traumatic event, their understanding of the event, and their feeling of safety after the event.

Which is not an important reason for the nurse to consider the children's mental health in the formulation of the plan of care for this particular client?

The children have a better chance of recovery from trauma than their mother due to their young age, so it is best to focus on them.

What are some realistic short-term outcome goals that the nurse should set with client related to the HCP's diagnosis of Post Traumatic Stress Disorder?

The client will speak about the trauma and express feelings of rage, guilt, fear, anxiety, and hopelessness.

If it is determined the client is dependent on alcohol, which information should the nurse obtain in order to predict the onset of withdrawal symptoms?

The last time the client consumed an alcoholic beverage.

Now that the nurse knows that a specific violent event has occurred, what is the nurse's responsibility to report the incident?

The nurse is not required to report the incident because it may put the client at greater risk.

Which of the significant other's behaviors exhibit codependency toward the client? (Select all that apply.)

The significant other states that moving out of their shared home caused the client to start drinking heavily. The significant other removed the hidden alcohol from the home and is now moving back in to keep a close eye on the client. The significant other has paid all of the bills for the next two months so that the client won't have to worry about finances when discharged.

Who should the nurse ask to complete the adverse event/incident report?

The technician helping at the time of the accident needs to complete the report.

What else can the nurse determine about these children's risk for emotional and behavioral problems from the assessment of the family so far?

They are more likely to suffer from emotional problems because their mother has a history of depression.

What is the best explanation for the husband's change in behavior and attitudes from the previous violent event to the Facebook messages asking for forgiveness?

This behavior is an expected part of the cycle of violence and is termed the honeymoon phase.

What data supports the need for admission to the hospital?

Thoughts of wanting to jump off a bridge.

What is the purpose of a baseline complete blood count (CBC) prior to initiation of the antipsychotic medication?

To determine if other medical issues are present.

What are important reasons for this teaching? (Select all that apply. One, some, or all options may be correct.)

To encourage the client to continue compliance with medications. To monitor for early tardive dyskinesia, which can be reversible. To reinforce education done throughout the hospitalization. To tell the cliet to discuss symptoms with his nurse.

What should the nurse anticipate if the client experiences symptoms of early withdrawal from alcohol?

Tremors, nausea, and vomiting.

Which items can the nurse allow the client to keep in the room? (Select all that apply.)

Unlaced tennis shoes. Electronic book reader. A personal photo.

Which is the best way for the nurse to screen for intimate partner violence?

Use an evidence-based tool such as the Abuse Assessment Screen.

Which behavior should the nurse avoid because it could make client less likely to disclose violence to you?

Using probing language to press for a response.

Which assessment is most important for safe alcohol detoxification?

Vital signs at least every 4 hours.

When should the nurse begin assessing for withdrawal?

Within 8-to-12 hours of the client's last drink.

How should the nurse document an assault such as the one the client just described in the record?

Write down verbatim the statements that the client makes related to who assaulted her and when.