Psych/Mental Health HESI Study Plan A

A client appears depressed and tense and reports various aches and pains since her spouse's death 3 months ago. Which intervention would the nurse use first?

Ask the client to talk about the spouse's death.

Which initial response would the nurse make to a client who is experiencing auditory hallucinations?

"I don't hear the voices you're hearing."

Which technique would the nurse use for a client with dementia who seems anxious, frequently paces about, and exhibits deteriorating hygiene?

Directing staff members to reinforce reality as needed

Which characteristics usually accompany obsessive-compulsive disorder?

Doubts, fears, and indecisiveness

Which question would the nurse ask to determine a client's potential for injury because of sleep deprivation? Select all that apply. One, some, or all responses may be correct.

"Do you operate heavy machinery at work?" "Does sleepiness affect your performance at work?"

Which response would the nurse make to a client with an obsessive-compulsive disorder who on the day of a job interview begins to display compulsive behavior?

"Going for your interview must be upsetting you. Describe what you're feeling now."

A person is badly disfigured by the lawnmower blade when mowing a lawn. Based on Erikson's psychosocial stages of development which age, at the time of injury, will be associated with the greatest risk of long-term psychological effects?

12 years

Which response would the nurse make to a client with borderline personality disorder who receives the wrong tray for lunch and becomes upset at the dietary staff regarding this mistake?

"It must be frustrating to get the wrong tray. I'll order another tray for you."

Which statement by the client would alert the nurse the client is experiencing a somatic delusion?

"My stomach has disintegrated."

Which statement indicates that the client is experiencing a crisis?

"Nothing I try works. Everything just keeps getting worse."

Which response would the nurse make to a client whose spouse recently died and who says, "What's the use in talking? I'd rather be dead. I can't go on without my spouse"?

"Are you thinking about killing yourself?"

Which statement correctly describes positron-emission tomography (PET)? Select all that apply. One, some, or all responses may be correct.

A radioactive tracer is injected

Which behavior is characteristic of panic during a crisis?

Being physically immobile

Which response would the nurse make to a client with a history of obsessive-compulsive behaviors who on the day of the part-time job interview arrives at the mental health center with signs of anxiety?

"Going for your interview triggered some feelings in you. Perhaps you could call a friend to drive you there."

Which response would the nurse make to a client with schizophrenia who says, "There are foreign agents conspiring against me; they're out to get me at every turn"?

"I can understand how frightening your thoughts are to you, but there are no foreign agents out to get you."

Which response would the nurse make to a client who says, "I suppose you're going to ask me about my suicide attempt"?

"Tell me how you feel about it."

Which response would best reflect that the anxious client's cognitive abilities have been affected by the anxiety when asked, "What brought you to the emergency department tonight"?

"The ambulance brought me to the emergency department."

Which intermediate outcome would the nurse add to the plan of care for a paranoid male client who has unjustifiably accused his wife of having many extramarital affairs?

"The client will develop feelings of self-worth."

Which initial question by the nurse would be most therapeutic to alleviate the anxiety of the client who is pacing the floor and appears extremely anxious?

"Where would you like to walk with me?"

Which priority factor would the nurse consider when planning care for a nursing home client who demonstrates numerous disorganized behaviors related to disorientation and cognitive impairment?

Ability to perform tasks without becoming frustrated

In comparing assessment findings in clients with vascular dementia and dementia of the Alzheimer type, which factor is unique to vascular dementia?

Abrupt onset of symptoms

Which initial intervention would the nurse perform for a client recently admitted with pacing, aloofness, and suspicion who says that other people have all the control?

Accepting the client's behavior

Which behavior would the nurse identify that a client with histrionic personality disorder is displaying when after being refused a sleeping pill, the client throws a book at the nurse?

Acting out

Which action would the nurse take for a person hospitalized for alcoholism who becomes boisterous, belligerent, and loud?

Administer the alcohol withdrawal medication.

At which point in the daily routine do clients who experience alterations in perception tend to have more problems with vivid hallucinations?

After going to bed

A recently widowed client says, "His death has complicated my life even more than the hassles he caused when he was alive!" Which term would best describe the marital relationship?

Ambivalent

Which behavior indicates codependence for the wife of a husband who abuses multiple drugs?

Attempts to cover up the husband's drug use

An unmarried pregnant client decides to keep the baby and is looking forward to motherhood. Which action best demonstrates the client's intrinsic motivation?

Client decides to attend prenatal childcare classes

Which principle would the nurse consider when planning care for a client who is using ritualistic behavior?

Clients do not want to repeat their rituals but feel compelled to do so.

Which factor would the nurse identify as likely related to the sleeplessness of a schizophrenic client who was transferred from a private room to a room with a roommate 3 days ago?

Fear of the client

During the termination phase of a therapeutic relationship, a client misses a series of appointments without any explanation. Which action would the nurse take?

Contact the client to encourage another session

Which defense mechanism manifests the client's emotional conflicts through motor, sensory, or somatic disabilities?

Conversion

A client says, "My legs are turning to rubber because I have an incurable disease called schizophrenia." Which alteration in perception is the client experiencing?

Depersonalization

According to Engel's 6 stages of grieving, which assessment is the most important to make for a dying client and the family during the developing awareness stage of grief?

Family's cultural background

Which therapeutic nursing intervention would redirect a hyperactive, manic client?

Encouraging the client to tear pictures out of magazines for a scrapbook

Which parental behaviors support a suspicion of child abuse? Select all that apply. One, some, or all responses may be correct.

Exhibiting difficulty in showing concern for their child Procrastinating in obtaining treatment for their child's injuries

Which behavior indicates that an older widowed client has successfully completed the grieving process?

Formulates a plan to start new relationships

Which rationale is the major reason that Narcotics Anonymous (NA) is helpful in treating addictive behavior?

Group members are supportive of one another's problems.

For a newly admitted client, which aspect of the therapeutic contract is the most important?

Helping the client define treatment goals and expectations

Which initial nursing intervention would the nurse implement for a client with the diagnosis of schizoid personality disorder?

Helping the client learn to trust the staff through selected experiences

To foster toilet training in a cognitively impaired child, which reward is best to reinforce appropriate use of the toilet?

Hug with praise

A client who has schizophrenia sees a group of visitors sitting together and says, "I know they're talking about me." Which altered thought process is the client demonstrating?

Ideas of reference

Which interventions would the nurse use to help a client who was in a same-sex relationship for 3 years and says, "My partner just left me. I'm a wreck"? Select all that apply. One, some, or all responses may be correct.

Identify the client's support systems. Encourage the client to talk about the situation

Which assessment finding would the nurse expect in a client with a history of sleeplessness, lack of interest in eating, and excessive purchases on charge accounts?

Intrusive involvement with environmental activities

Besides encouraging nourishment, which rationale would explain the reason nurses are assisting a depressed client with meals who is eating very little?

It demonstrates that the staff considers the client a worthwhile individual.

For clients who are addicted to alcohol, which rationale explains why denial is a primary defense mechanism?

It reduces feelings of guilt.

When a newly admitted client with paranoid ideation talks about people coming through the doors to commit murder, which action would the nurse use?

Listen attentively to what the client is saying.

Which nursing objective would be essential in the therapeutic psychiatric environment for a confused client?

Maintaining the highest level of safe, independent function

Which behavior indicates that the therapy group has reached the working stage?

Members focus on a variety of needs and concerns.

A client reports overwhelming and irresistible attacks of sleep. Which sleep disorder is she or he describing?

Narcolepsy

Which consideration is of primary importance when planning for a therapy group?

Needs of the clients being included

Which characteristic about confusion would the nurse keep in mind when an older client with Alzheimer disease is admitted to a long-term care facility?

Occurs with a transfer to new surroundings

Which action would the nurse take to help a disturbed, acting-out child develop a trusting relationship?

Offer periodic support while emphasizing safety in play activities.

A hostile client with the diagnosis of schizophrenia, says, "The voices are saying that they are going to poison me because I'm bad." Which type of schizophrenic behavior is the client displaying?

Paranoid

Which relationship is the most important to the formation of personality?

Parent-child relationships

Which parameter would be assessed to determine the degree of anxiety being experienced by the client?

Perceptual field

When planning care, which important guideline would the nurse use for a client who is using paranoid ideation?

Providing the client with activities that are structured and predictable

Which response would the nurse make when a client who is actively hallucinating reports, "I'm hearing voices that are saying bad things about me"?

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

A client is exclusively preoccupied with thoughts of her mother's death. According to Engel's stages of grieving, which stage is the client experiencing?

Resolving the loss

Which signs and symptoms support the conclusion that the client has been abusing high-dose cocaine for a prolonged time? Select all that apply. One, some, or all responses may be correct.

Sadness Psychomotor retardation

Which fear is the inexperienced nurse most likely manifesting when she opts to begin a one-on-one therapeutic relationship with a depressed, withdrawn older client?

Saying the wrong thing to a more alert client

Which initial action would the nurse take for a young client with anorexia nervosa who phones home just before each mealtime and then refuses to eat food that has gotten cold?

Schedule a family meeting to discuss the problem.

Which behavior would alert the nurse that a child is demonstrating outwardly focused anger or aggression in an overt manner?

Scribbling on a classmate's art assignment

Which intervention would be important when caring for a client who was admitted yesterday with borderline personality disorder (BPD)?

Setting limits

Which topic would be most important for the nurse to address at a group session for 3 chronically ill clients who have the diagnosis of schizophrenia?

Social skills in group settings

The client who is dying asks that pain medication be left on the bedside table; the staff has mixed feelings about the terminal status, prolonged pain, and possible suicidal ideations. Which intervention would the charge nurse use?

Suggest a nursing conference to discuss the medication problem and the staff's feelings.

Which approach would the nurse use to bolster a healthy adolescent's self-esteem who develops a personal goal of earning money?

Supporting the adolescent's interest in enrolling in a babysitting course

Which action would the nurse take for a client with paranoid schizophrenia who wraps the legs in toilet paper, believing that this will provide protection from deadly germs contaminating the floor?

Talk with the client about anxiety that focuses on health.

Which information would the nurse include in family teaching regarding the client's use of confabulation?

The client is making up what cannot be remembered.

Which legal aspect would be indicated when a nurse informs the nosy, hyperactive client, "Unless you're quiet, you'll be isolated and put in restraints, if necessary"?

The information given to the client is actually considered assault.

Which benefit accompanies mild apprehension?

There is an increased alertness.

Which term describes what an adolescent client is experiencing when she says to the nurse who has been caring for her, "You're just like my mother; I hate you"?

Transference

Which information would the nurse provide an older adult and caregivers regarding medication safety? Select all that apply. One, some, or all responses may be correct.

Use a pill organizer. Read all medication labels. Review the medications with a pharmacist.

Which intervention would the nurse implement for a client prescribed haloperidol for schizophrenia? Select all that apply. One, some, or all responses may be correct.

Using the Z-track method for all irritation medications

Which instructions would the nurse include regarding how to help prevent or identify impending relapse for a group of clients who experience bipolar disorder, manic episodes? Select all that apply. One, some, or all responses may be correct.

Watch for changes in libido. Keep dietary changes to a minimum. Maintain a regular sleeping schedule. Monitor yourself for increased irritability or mood instability.