Mental Health Practice HESI
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?
"Are you ever alone when you hear the voices?"
The nurse is taking a history for a female client who is requesting a routine female exam. Which assessment finding requires follow-up?
"Black-out" after one drink last night on a date.
A 45-year-old male client tells the nurse that he used to believe that he was Jesus Christ, but now he knows that he is not. Which response is best for the nurse to make?
"I think you're getting well."
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?
"Yes, I will be leading this group. What would you like to accomplish during this time?"
A client is admitted with a diagnosis of depression. The nurse knows that which characteristic is most indicative of depression?
A negative view of self and the future.
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 his behavior?
Allow time for the ritualistic behavior, then redirect the client to other activities.
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?
Confront her fears and discuss the possible causes of these fears.
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?
Medication Management.
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?
Moderate levels of anxiety.
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?
Provide a structured environment with little stimuli.
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?
Psychotic.
A female client refused 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?
Reassess client's mental status for thought processes and content.
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?
Risk for injury related to alcohol detoxification.
The nurse observes a client who is admitted to the mental health unit and identifies that the client is talking continuously, using the words that rhyme but that have no context or relationship with one topic to the next in conversation. This client's behavior and thought processes are consistent with which syndrome?
Schizophrenia.
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?
Stagnation
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?
Talk to the client outside the group about his behavior during group meetings.
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, its not MY fault. You can't blame me. I didn't kill him, you did." What action is best for the nurse to take?
Tell the client that no one is accusing him of murder and remind him that the hospital is a safe place.
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?
Tell the client that the nurse is there and will help her.
Based on non-compliance with the medication regimen, an adult client with a medical diagnosis of substance abuse with schizophrenia was recently switched from oral fluphenzine HCl (Prolixin) to IM fluphenazone decanoate (Prolixin Decanoate). What is most important to teach the client and family about this change in medication regimen?
The effects of alcohol and drug interaction.
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?
The nurse should report any case of suspected child abuse to the nurse in charge.
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
dissociative disorder.
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
encourage the client to actively participate in assigned activities on the unit.
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?
Decreased thyroid stimulating hormone level.
The nurse should hold the next scheduled dose of a client's haloperidol (Haldol) based on which assessment finding(s)?
Fever of 102 F.
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?
Immediately transfer the client to the ICU.
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?
Redirect the client's energy by asking him to tidy the recreation room.
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?
"Come with me to your room and I will sit with you."
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?
"Keep your dietary salt intake consistent."
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?
Ask one nurse to spend time with the client daily.
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?
Chlordiazepoxide (Librium).
A female client with 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.)
Compulsions relieve anxiety. Anxiety is the key reason for OCD. Obsessive thoughts are linked to levels of neurochemicals. Antidepressant medications increase serotonin levels.
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?
Increased self-understanding.
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
Low self-esteem
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?
Maintain safety in the client's milieu.
A client who is being treated with lithium carbonate for bipolar disorder develops diarrhea, vomiting, and drowsiness. What action should the nurse take?
Notify the healhcare provider immediately and prepare for administration of an antidote.
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?
Roast beef, baked potato with butter, and iced tea.
The nurse suspects child abuse when assessing a 3-year-old boy and noticing several small, round burns on his legs and trunk that might be the result of cigarette burns. Which parental behavior provides the greatest validation for such suspicions?
The parents tell the nurse that the child was burned in a house fire which is incompatible with the nurse's observation of the type of burn.
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?
He is unresponsive to instructions and is unable to cooperate with emetic therapy.
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?
Suggest another way for this client to partipate in the unit's activities.
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?
"I will die if my cat dies."
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?
"I'll be back in 30 minutes to help you get out of bed and walk around the room."
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?
"It is a chemical imbalance in the brain that causes disorganized thinking."
The nurse is leading a "current events group" with chronic psychiatric clients. One group member states, "Clara Barton was my nurse during my last hospitalization. She was a very mean nurse and wasn't nice to me." Which response would be best for the nurse to make?
"What did she do to you that was so mean?"
The nurse observes a female client with schizophrenia watching the news on TV. She begins to laugh softly and says, "Yes, my love, I'll do it." When the nurse questions the client about her comment she states, "The news commentator is my lover and he speaks to me each evening. Only I can understand what he says." What is the best response for the nurse to make?
"What do you believe the news commentator said to you?"
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?
"Remember I told you that this is a nursing home and I am your nurse."
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?
Ask the client if he takes St. John's Wort routinely.
The nurse is planning the care for a 32-year-old male client with acute depression. Which nursing intervention would be best in helping the client deal with his depression?
Ensure that the client's day is filled with group activities.
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?
Participate in a group quilting project.
Which statement about contemporary mental health nursing practice is accurate?
The psychiatric nursing client may be an individual, family, group, organization, or community.
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?
"Let's talk about what is right with your life."
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?
"My mouth feels like cotton."
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?
"Only my belief in God can help me."
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?
Agoraphobia.
At a support meeting of parents of a teenager with polysubstance dependency, a parent states, "Each time my son tries to quit taking drugs, he gets so depressed that I'm afraid he will commit suicide." The nurse's response should be based on which information?
Careful monitoring should be provided during withdrawal from the drugs.
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?
Flat affect.
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?
Identification
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
projecting her feelings onto the nurse.
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?
"I'll leave your tray here. I am available if you need anything else."
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?
"Let me call and leave a message for your healthcare provider."
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?
"Let's talk about what happens when you feel very anxious."
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?
"Rape is not limited to strangers and frequently occurs by someone who is known to the victim."
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?
"Tell me more specifically about your child's accidents."
A male client with schizophrenia who is taking fluphenazine decanoate (Prolixin decanoate) is being discharged in the morning. A repeat dose of medication is scheduled for 20 days after discharge. The client tells the nurse that he is going on vacation in the Bahamas and will return in 18 days. Which statement by the client indicates a need for health teaching?
"When I return from my tropical vacation, I will go to the clinic to get my Prolixin injection."
A 52-year-old male client in the intensive care unit who has been oriented suddenly becomes disoriented and fearful. Assessment of vital signs and other physical parameters reveal no significant change and the nurse formulates the diagnosis, "Confusion related to ICU psychosis." Which intervention would be best to implement?
Cluster care so that brief periods of rest can be scheduled during the day.
A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care?
Excessive CNS stimulation will be reduced.
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?
His case manager.
The parents of a 14-year-old boy bring their son to the hospital. He is lethargic, but responsive. The mother states, "I think he took some of my pain pills." During initial assessment of the teenager, what information is most important for the nurse to obtain from the parents?
If he might have taken any other drugs.
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?
Ineffective denial related to situational anxiety.
The nurse should include which interventions in the plan of care for a severely depressed client with neurovegetative symptoms? (Select all that apply.)
Permit rest periods as needed. Speaking slowly and simply. Allow the client extra time to complete tasks. Observe and encourage food and fluid intake. Encourage mild exercise and short walks on the unit.
