Mental Health HESI Final Study

A nurse is working with a married woman who has come to the emergency department several times with injuries that appear to be related to domestic violence. While talking with the nurse manager, the nurse expresses disgust that the woman keeps returning to the situation. What is the best response by the nurse manager?

"Most women try to leave about six times before they are successful."

A man with bipolar disorder, manic episode, has been traveling around the country, dating multiple women, and buying his dates expensive gifts. He is admitted to the hospital when he becomes exhausted and runs out of money. The nurse anticipates that during a manic episode the client is most likely experiencing feelings of what?

Grandeur

Although upset by a young client's continual complaints about all aspects of care, the nurse ignores them and attempts to divert the conversation. Immediately after this exchange with the client, the nurse discusses with a friend the various stages of development of young adults. Which defense mechanism is the nurse using?

Intellectualization

To provide appropriate psychosocial support to clients, a nurse must understand development across the life span. What theory is the nurse using in considering relationships and resulting behaviors as the central factors that influence development?

Interpersonal theory

A nurse is conducting a group therapy session. Why is a group setting especially conducive to therapy?

It provides a new learning environment.

A client who is to be discharged from an inpatient mental health facility is referred to a mental health daycare center in the community. What should the nurse identify as the primary reason for this referral?

Maintaining gains achieved during hospitalization

A client has just awakened from her first electroconvulsive therapy (ECT) treatment. What is the most appropriate initial intervention by the nurse?

Orienting the client to time and place and explaining that the treatment is over

Which relationship is of most concern to the nurse because of its importance in the formation of the personality?

Parent-Child

A client with the diagnosis of dementia of the Alzheimer type, stage 1, is living at home with an adult child. To best address the functional and behavioral changes associated with this stage, what should the nurse encourage the daughter to do?

Post a schedule of the client's daily activities.

A nurse recalls that the environment is important when caring for a client with the diagnosis of bipolar II disorder with manic episodes. What should the nurse do when caring for clients with this disorder?

Provide a quiet atmosphere by placing the client in a private room.

What should the nurse include when developing a plan of care for an older client with a diagnosis of dementia?

Provide consistency in carrying out nursing activities for the client

A client in the mental health clinic who has concerns about getting married says to the nurse, "I guess I'd better get married. All the plans are made and paid for, and the invitations have all been mailed." What defense mechanism is the client using?

Rationalization

The wife of a client who is dying tells the nurse that although she wants to visit her husband daily, she can visit only twice a week because she works and has to take care of the house and their cat and dog. What defense mechanism does the nurse conclude that the client's wife is using?

Rationalization

A client who is hallucinating actively approaches the nurse and reports, "I'm hearing voices that are saying bad things about me." What should the nurse do?

Reply, "I'll stay with you for a while; you seem frightened."

A nurse is interviewing a mother accused of physical child abuse. When speaking with this mother, what does the nurse expect her to do?

Reveal the belief that her child needed to be disciplined.

The primary objective of nursing intervention for clients with dementia, delirium, and other cognitive disorders is to maintain what?

Safety

A client has just been admitted to the psychiatric unit on involuntary admission status. During the admission assessment the client tells the nurse, "I am the second son of God and need to say a prayer." What is the best response by the nurse?

Waiting until the client finishes the prayer and then completing the assessment

A nurse enters a client's room and notes that the client appears preoccupied. Turning to the nurse, the client says, "They're saying terrible things about me. Can't you hear them?" What is the most therapeutic response by the nurse?

"I don't hear anyone else talking, but I can see that you're upset."

A male client with dementia due to Parkinson disease has been placed in a nursing home. His wife appears tired and angry on her first visit with her husband. As she is leaving she says to the unit nurse in a sarcastic tone, "Let's see what you can do with him." What is the most therapeutic response by the nurse?

"It sounds like it's been difficult for you."

A nurse is interviewing a client with the diagnosis of dementia of the Alzheimer type. What question should the nurse ask to assess the client's orientation to place?

"Where are you?"

A child dies after an explosion at school. The parents arrive at the hospital a few minutes later and are told what happened. The parents ask the nurse whether they may see their child. What is the best response by the nurse?

"You may see your child now."

At what age is a client in Freud's phallic stage of psychosexual development and Erikson's psychosocial phase of initiative versus guilt?

3-5 years

How should a nurse characterize a sudden terrorist act that causes the deaths of thousands of adults and children and negatively affects their families, friends, communities, and the nation?

Adventitious

What clinical manifestation best indicates to the nurse that the mental status of a client with the diagnosis of schizophrenia, paranoid type, is improving?

Ability to function effectively in activities of daily living

Before effectively responding to a sexually abused victim on the phone, it is essential that the nurse in the rape crisis center do what?

Be aware of any personal bias about sexual assault.

Honor the client's decision and document the behavior and all interventions.

By offering choices consistent with the client's heritage

A nurse is caring for a newly admitted client with anorexia nervosa. What is the priority treatment for the client at this time?

Correction of electrolyte imbalances

Be aware of any personal bias about sexual assault.

Daily drinker

A nurse is conducting a therapy group whose objectives are to assist the members to gain insight and to change behavior so they are able to participate in life in a more satisfying manner. What leadership style will best help the nurse achieve these objectives?

Democratic, guiding

A client who is in a manic phase of bipolar disorder threatens staff and clients on a psychiatric acute care unit. Place these interventions in priority order, from the least to the most restrictive.

Diversional activities, Limit-setting, Medication administration, Seclusion, Restraints

A nurse in a hospice program cares for clients and family members who are coping with imminent loss. What is the most important factor in predicting a person's potential reaction to grief?

Earlier experiences with grief

A nurse understands that autism is a form of a pervasive developmental disorder (PDD). Which factor unique to autism differentiates it from other forms of PDD?

Early onset, before 36 months of age

The nurse assesses a client with the diagnosis of bipolar disorder, manic episode. Which clinical findings support the diagnosis? Select all that apply.

Grandiosity, Talkativeness, Distractibility

Nurses working with clients who have a diagnosis of dementia should adopt a common approach of care, because these clients have a need to do what?

Have sameness and consistency in their environment

To further assess a client's suicidal potential, the nurse should be especially alert to the client's expression of what?

Helplessness and hopelessness

A nonviolent client on the psychiatric unit suddenly refuses to take the prescribed antipsychotic medication. What should the nurse do?

Honor the client's decision and document the behavior and all interventions.

A college student is brought to the mental health clinic by parents with a diagnosis of borderline personality disorder. Which factors in the client's history support this diagnosis? Select all that apply.

Impulsiveness, Lability of mood, Self-destructive behavior

An adult with the diagnosis of schizophrenia is admitted to the psychiatric hospital. The client is ungroomed, appears to be hearing voices, is withdrawn, and has not spoken to anyone for several days. What should the nurse do during the first few hospital days?

Seek out the client frequently to spend short periods of time together

A nurse is working in the orientation phase of a therapeutic relationship with a client who has borderline personality disorder. What will be most difficult for the client at this stage of the relationship?

Setting mutual goals for the relationship

A nurse believes that a client who is being discharged after a physical attack by an unknown assailant will benefit from further care to help resolve residual feelings. For what type of therapy should the nurse refer the client?

Short-term therapy emphasizing crisis intervention

A client who has been hospitalized with schizophrenia tells the nurse, "My heart has stopped and my veins have turned to glass!" What should the nurse conclude that the client is experiencing?

Somatic delusion

A client has been diagnosed with generalized anxiety disorder (GAD). Which behavior supports this diagnosis?

Spending hours each day worrying about something "bad happening"

Two 14-year-old girls are best friends and always eat lunch together at school. One of the girls eats rapidly and then immediately leaves to go to the girls' restroom. After a week or so the other girl begins to suspect that her friend is using self-induced vomiting to keep her weight down. Because the friend is not sure what to do, she speaks with a relative who is a nurse. What should the nurse encourage her to do?

Talk to the school nurse about her concerns.

A high school-age adolescent undergoing lithium therapy has not been following the prescribed pharmacologic regimen. What should the school nurse do to help promote adherence to the regimen?

Talk with the adolescent about the importance of a consistent lithium blood level in ensuring that the medication will be effective

A client with a history of violence is increasingly agitated. Which immediate nursing intervention will most likely increase the risk of acting-out behavior?

Teaching relaxation techniques

A woman who gave birth to a second child 3 weeks ago is depressed and having difficulty caring for her children. At the end of the day both of the children are dirty, wet, and crying. The woman tells her husband that she "just can't take this anymore." The husband calls the women's health clinic and asks what he should do. What is the best response by the nurse?

Telling him that his wife may be suffering from depression and needs emergency care

A client confides to the nurse, "I've been thinking about suicide lately." What conclusion should the nurse make about the client?

The client is fearful of the impulses and is seeking protection from them.

How should a nurse intervene when a confused and anxious client voids on the floor in the sitting room of the mental health unit?

Toilet the client more frequently with supervision.