Psych HESI
An older adult client asks the nurse to kill the bugs that are crawling on the floor of the room. the nurse does not see any bugs and suspects the client is hallucinating. Which statement by the nurse to the client is *most* appropriate? A. "It may seem to you that there are bugs on the floor, but I do not see any bugs." B. "I see them too. They are crawling all over the floor. How should I kill them?" C. "Can you tell me more about these bugs?" D. "Tell me, what do these bugs look like?"
A. "It may seem to you that there are bugs on the floor, but I do not see any bugs." Rationale: This response validates what the client is seeing. To the client, a hallucination is real. However, the nurse must reorient the client to the appropriate reality and try to restore the client's feelings of safety.
The parent of an adolescent client, who has permission to be involved in the plan of care, asks the nurse questions, after it has been explained to that the child has bipolar disorder. Which parental statement indicates that further teaching is needed? A. "My child will be cured after being on medications for a few months." B. "My child will require support and encouragement." C. "My child will be on the psychiatric medications probably for the rest of her life." D. "The goal of the medication is to reduce symptoms and help with mood swings."
A. "My child will be cured after being on medications for a few months." Rationale: Bipolar disorder is not curable. Clients can suffer from bipolar disorder throughout their entire lives. The mother's statement that the child will be cured after being on medication indicates further teaching about the disorder is needed.
The nurse learns that a client's sibling passed away during a recent hospitalization, and the client is distraught by this news. Which action does the nurse implement *first*? A. Allow the client to verbalize feelings, and inquire if the client would like to be visited by social services, chaplaincy, or psychiatry for support B. Provide alone time by not going into the client's room unless absolutely necessary C. Call psychiatry services to arrange for them to see the client as soon as possible D. Find out which religion the client practices by viewing the chart and then request a chaplain from that religion to see the client
A. Allow the client to verbalize feelings, and inquire if the client would like to be visited by social services, chaplaincy, or psychiatry for support Rationale: Allowing the client an opportunity to verbalize feelings, and inquiring if the client would like to be visited by social services, chaplaincy, or psychiatry are all appropriate for the nurse to do.
The nurse admits a non-English-speaking client who is accompanied by family members who speak English. The nurse needs to ask general admission questions. It is *most* appropriate for the nurse to take which action? A. Call the hospital's interpreter services to assist with asking the client questions B. Ask family members the questions and document their responses C. Ask family members to translate and ask the questions for the nurse D. Document "Unable to obtain answers, patient does not speak English."
A. Call the hospital's interpreter services to assist with asking the client questions Rationale: The only way to avoid bias and interjection by family members is by utilizing interpreter services at your hospital.
A client requires a blood transfusion. The client refuses based on religious beliefs. It is *most* appropriate for the nurse to take which action when providing care to this client? A. Confirm with the client that the client understands the potential risks of not having the blood transfusion B. Tell the client that, regardless of personal beliefs, the client has to have the lifesaving transfusion C. Call the legal department of the hospital immediately D. Gently encourage the client to accept the transfusion
A. Confirm with the client that the client understands the potential risks of not having the blood transfusion Rationale: The nurse must be sure the client understands the potential risks of not receiving the transfusion.
During the admission process, the nurse inquires about advance directives from the client. The client tells the nurse, "I do not want to make any medical decisions. I want my daughter to make these decisions for me." Which action does the nurse implement based on the current situation? A. Make sure that the written advance directives document the client's wishes B. Tell the client that, being alert and oriented, the client should make his or her own medical decisions C. Tell the client that that due to confidentiality, the daughter will not be informed of details of the client's care D. Encourage both the daughter and the client to work together on making medical decisions
A. Make sure that the written advance directives document the client's wishes Rationale: As long as the client is not pressured into this decision and the nurse believes that it is being made of the client's free will, it is acceptable for the daughter to take over medical decision making for the ill parent.
The nurse cares for a client who is intoxicated, has signs of delirium, and attempts to get out of bed every few minutes. The client's gait is unsteady and the nurse is concerned that the client might fall. The provider prescribes wrist restraints. The client refuses the restraints. The nurse should take which action? A. Place the retrains in compliance with hospital policy B. Refrain from placing restraints to honor the client's wishes, because he has the right to refuse care C. Call the provider for advice on how to proceed D. Check on the client every hour to ensure his safety
A. Place the retrains in compliance with hospital policy Rationale: The nurse should place the restraints in compliance with hospital policy. This is a circumstance where the client's risk of harm and promotion of safety overrules the client's right to refuse.
The nurse cares for a client who is a recently returned combat veteran. The client exhibits signs of anxiety and hostility. The nurse should assess the client for which of these conditions? A. Post-traumatic stress disorder (PTSD) B. Bipolar disorder C. Schizophrenia D. Boderline personality disorder (BPD)
A. Post-traumatic stress disorder (PTSD) Rationale: PTSD is a known disorder from which Veterans of war can suffer. Any thorough evaluation of symptoms would include one for PTSD.
The nurse provides care to a client, diagnosed with Alzheimer's disease, who is agitated and pulling at things. Which action should the nurse implement when providing care to this client? A. Provide the client with therapeutic sensory devices B. Cohort the client with another client who is agitated, because they will calm each other C. Place the client in a room with several other clients D. Leave the client alone for a set period of time to reduce environmental stimulation
A. Provide the client with therapeutic sensory devices Rationale: Clients with Alzheimer disease often pick at items, such as buttons on clothing or medical devices, which poses a danger to them. Providing them with safely designated sensory devices serves the need of stimulating the sense was well as their urge to pick.
The nurse cares for a hospice client who lives at home with an attentive spouse. The client's spouse quit work to care for the client. During the nurse's visit, the spouse expresses frustration and hostility toward the nurse. Which is an appropriate response by the nurse? *Select all that apply.* A. The nurse should encourage the spouse to verbalize feelings B. The nurse should encourage the spouse to attend a caregiver support group C. The nurse should encourage the spouse to go back to work part-time D. The nurse should encourage the spouse not to verbalize negative feelings that may upset the client E. The nurse should ignore the spouse's hostile behavior
A. The nurse should encourage the spouse to verbalize feelings B. The nurse should encourage the spouse to attend a caregiver support group Rationale: (A) Verbalizing feelings is an appropriate intervention for family members suffering from caregiver role strain. (B) Attending a support group is an appropriate intervention for family members suffering from caregiver role strain. Encouraging the spouse to not verbalize negative feelings interferes with natural expression and personal family conversations.
The nurse cares for a terminally ill client who has agreed to enter hospice care. Which statement by the spouse indicates a need for further teaching by the nurse? A. "You will help to make my spouse as comfortable as possible while in hospice care." B. "You will help my spouse get better so we can get back to our old life." C. "The goal is to make the end of my spouse's life as comfortable as possible." D. "You will provide me with much needed support during this difficult time."
B. "You will help my spouse get better so we can get back to our old life." Rationale: This is an inaccurate statement. The philosophy of hospice care is not to help a client recover, but to promote comfort and peace during the end of life. The presumption is that the client will not improve.
The clinic nurse cares for a client who appears intoxicated and drove to the appointment. The nurse is concerned about the client's ability to drive home. Which action should the nurse implement *first*? A. Call the police and confiscate the client's driver's license B. Ask the client's permission to call a family member for a ride C. Give the client a ride home to protect his privacy D. Call clinic security to detain the client to protect his safety
B. Ask the client's permission to call a family member for a ride Rationale: Asking the client's permission to call a family member is a better option because it includes the client in the choice. An intoxicated client may not make good choices, but the client may be amenable to good suggestions. Ideally, the nurse would find somebody (not the police) to get the client home safely. that would allow maintaining a trusting nurse-client relationship.
A client with post-traumatic stress disorder (PTSD) appears to be experiencing a flashback. It is *most* appropriate for the nurse to perform which intervention? A. Encourage the client to tell the nurse how the client is feeling in that moment B. Calmly reorient the client to the current situation C. Assist the client in acting out the flashback event D. Inform the client firmly that what the client is experiencing is not real
B. Calmly reorient the client to the current situation Rationale: The nurse wants to calmly orient the client back to the reality of the moment, to the actual safe environment.
The nurse provides care to a client who experiences a manic episode. It is *most* appropriate for the nurse to perform which intervention for this client? A. Give the client materials to make a collage B. Encourage the client to use an exercise bike C. Let the client attend a group about managing feelings D. Ask the client to play a board game with other clients
B. Encourage the client to use an exercise bike Rationale: The exercise bike would allow an outlet for the client's excessive energy.
The nurse completes a health history for a client. the client has been taking lorazepam for 6 months. Which finding does the nurse anticipate when conducting the physical examination for this client? A. Excessive appetite B. Physical dependence C. Suicidal ideation D. Seizure activity
B. Physical dependence Rationale: Clients can experience all types of side effects from benzodiazepines, but the most likely side effect from prolonged use is physical dependence.
The nurse works on a busy locked psychiatric unit. The alarm is activated when someone tries to go through the locked door without permission from the front desk. Which action does the nurse take after the alarm is activated? A. Reset the alarm from the front desk after verifying that everybody is safe and nobody has escaped from the unit B. Reset the alarm from the location where the alarm was activated after verifying that everybody in the unit is safe C. Reset the alarm from a client's room after doing a quick scan of the hallways and bathrooms D. Reset the alarm from the front desk once the receptionist says everybody is accounted for
B. Reset the alarm from the location where the alarm was activated after verifying that everybody in the unit is safe An alarm is a safety mechanism meant to alert staff to somebody at risk attempting to leave. When an alarm is activated, the nurse should first make sure that all clients are accounted for and safe, an then reset the alarm by going to the place where it was tripped.
The nurse cares for the male client who has expressed a desire to commit suicide. He has informed the nurse of plans to pursue this. The nurse requests a sitter to stay with the client around the clock, but the client says he does not want this. Which of these is the *most* appropriate responses by the nurse? A. The nurse allows the young man to refuse, because clients do have a right to refuse care B. The nurse implements the intervention, because protecting the client's safety overrules the client's right to refuse care C. The nurse checks on the client every hour to be sure he is safe and the sitter is fine D. The nurse asks the unlicensed assistive personnel (UAP) to check on the client every 30 minutes to be sure he is safe
B. The nurse implements the intervention, because protecting the client's safety overrules the client's right to refuse care Rationale: Protecting the client's safety trumps the client's right to refuse care.
The nurse works in a day program for clients with disabilities. The nurse notes that an adolescent client is frequently alone and often quiet. It is *most* appropriate for the nurse to take which action when providing care for this client? A. Allow the client alone time since the client prefer this B. Make an effort to interact with the client periodically C. Encourage the quiet client to join a youth group D. Encourage others to interact more frequently with the client
C. Encourage the quiet client to join a youth group Rationale: Participating in a youth group can help a teenage client with a disability develop social skills, use support systems, and feel more like a typical teenager.
The nurse cares for a client who will undergo a mastectomy in the morning. A call from the front desk alerts the nurse that the client's family has arrived. It would be *most* appropriate for the nurse to take which of these actions? A. Tell the family that they cannot come in because visiting hour are over B. Tell the client you want to make sure she has some alone time to relax C. Invite the family in to offer support after confirming with the client D. Tell the unlicensed assistive personnel (UAP) to sit with the client who needs company
C. Invite the family in to offer support after confirming with the client Rationale: During time of stress and anxiety, such as undergoing surgery, nurses should promote family support. The answer choice also states that the nurse would ask the client first. This supports including clients in their care.
The nurse cares for a client with a known past medical history for intravenous substance abuse. The client requests to go outside to smoke and promises to come right back. The client has a peripheral intravenous line in. Which action does the nurse implement based on the current scenario? A. Allow the client to go outside but set a time limit in which to return B. Secure the intravenous line with occlusive dressing and call security to escort the client to an approved smoking area C. Make a behavioral contract with the client that includes an agreement to have an unlicensed assistive personnel accompany the client D. Watch the client from the window to make sure the IV line stays open
C. Make a behavioral contract with the client that includes an agreement to have an unlicensed assistive personnel accompany the client Rationale: Contracting with the client is the best choice. The nurse makes a compromise that the client can go outside but must be supervised while doing so. The client is a known abuser of intravenous substances, so sending the client outside alone could be a safety risk.
The nurse provides care to a client who has experienced a depressed mood, decreased sleep, poor concentration, and poor appetite for the past 4 months. The nurse anticipates that the provider will prescribe which medication? A. Quetiapine B. Haloperidol C. Mirtazapine D. Clonazepam
C. Mirtazapine Rationale: Mirtazapine is typically prescribed for depression. Quetiapine is not typically given for depression symptoms; it is usually given for bipolar disorder. Haloperidol is given for symptoms of schizophrenia, not depression. Clonazepam is more typically given for panic disorders.
The nurse discovers a hospice client has expired. The family members are regrouping in the facility's waiting room. Which action by the nurse is *most* appropriate? A. Tell the family it would not be in their best interests to see their loved one B. Encourage the family to view the body to help accept the situation C. Provide condolences to the family and offer them viewing time D. Tell the family, "I will give you some time to spend with your loved one. Let me know if you need anything."
C. Provide condolences to the family and offer them viewing time Rationale: The nurse acknowledges the loss, expresses sympathy, and offers the viewing opportunity.
The nurse makes a home visit to a pediatric client with a gastrostomy tube. Upon arrival, the nurse notices that the client's sibling is wearing dirty clothes that are too small. The nurse also notices that there is no food in the refrigerator or in the kitchen cabinets. Which option *most* appropriately describes how the nurse should respond to these observations? A. The nurse should not be concerned because the sibling is not her client and the client is being fed via a gastrostomy tube B. The nurse should not be concerned because there are no signs of physical abuse C. The nurse should be concerned and take action because there is no food or appropriate clothing available to the sibling D. The nurse should not be concerned because her client is well cared for
C. The nurse should be concerned and take action because there is no food or appropriate clothing available to the sibling Rationale: As a mandated reporter, the nurse needs to investigate to determine if there is a reasonable explanation: for example, the sibling just came in from playing and the parents are on their way to buy food.
A client scheduled to have surgery tells the nurse, "I'm very scared. I have never had surgery before and am afraid that I might not make it through." Which response by the nurse is *best*? A. "Why do you feel this way?" B. "Don't worry, you will be fine." C. "Why don't we take some time to fully explore why you feel this way?" D. "It's normal to be scared. You will be taken care of. Tell me how you are feeling."
D. "It's normal to be scared. You will be taken care of. Tell me how you are feeling." Rationale: A response that tells the client that it is normal to be scared, and that he will be taken care of, and asks how he is feeling, normalizes the client's experience, provides some reassurance, and allows for him to verbalize.
The nurse cares for a client diagnosed with alcohol abuse who reports having the last drink yesterday. The client exhibits tremors, diaphoresis, and tachycardia. Based on the current data, which action does the nurse implement *first*? A. Call the health care provider to report the symptoms and administer hydromorphone per the alcohol withdrawal pathway B. Assess client every hour to monitor for worsening symptoms C. Call the family and administer meperidine per the alcohol withdrawal pathway D. Administer lorazepam per the alcohol withdrawal pathway
D. Administer lorazepam per the alcohol withdrawal pathway Rationale: Benzodiazepines such as lorazepam are often given as part of an alcohol withdrawal pathway; this client is clearly beginning to exhibit symptoms of withdrawal by having tremors, diaphoresis, and an elevated heart rate. Hydromorphone is for pain and not for management of alcohol withdrawal.
The nurse on the inpatient psychiatric unit cares for a client with known suicidal ideation. The 24-hour observer calls the nurse to report that the client took off down the hall. The nurse is unable to immediately locate the client. Arrange the following actions by the nurse in the order that is *most* appropriate. *All options must be used.* A. Notify security and provide a description of the client B. Notify the nurse manager C. Notify other staff on the unit D. Ask the observer in what direction the client headed
D. Ask the observer in what direction the client headed C. Notify other staff on the unit A. Notify security and provide a description of the client B. Notify the nurse manager Rationale: (D) Asking the observer which direction the client headed is the first step. This enables the nurse to give accurate information to staff, and if necessary, security to help locate the client. (C) Notifying other staff is the second step because they know the client and are readily available to search locally. (A) Security is the third step because, although they are not immediately on hand, they can have multiple people search from different directions. (B) Notifying your nurse manager is the last step, because the manager may not be readily available. Your priority is locating client and ensuring the client's safety.
The home care nurse makes a visit to the home of an older client who has episodic confusion but remains safe at home while occasionally alone. The nurse finds the client disheveled, confused, and agitated, and the home is messy. This degree of confusion is unusual for the client. the nurse takes the client's vital signs, which are BP 115/70 mmHg, HR 70 bpm, RR 16 bpm, and temperature 98.8* F (37*C). Which action should the nurse implement *first*? A. Nothing, because the client's vital signs are stable B. Plan to come back the following day to reevaluate the client C. Sit down with the client and encourage client to verbalize feelings D. Call the client's family to take the client to be evaluated by a provider
D. Call the client's family to take the client to be evaluated by a provider Rationale: These are new symptoms , and the client does not appear safe to be alone. By contacting the family, the nurse is performing an intervention based on the assessment of the client. In the home care setting, assessing safety is prioritized, especially with new symptoms.
The pediatric provides care to a client who is 13 months of age and diagnosed with failure to thrive (FTT). The parents report that the child cries frequently, does not like to be held, and will not eat. The nurse learns that the child's uncle lives in the house with the family. When the uncle visits in the hospital, the nurse notices the child acting differently and turning away from the uncle. Sometimes the child's heart rate increases when the uncle is present. Which is the *priority* action by the nurse? A. Immediately report the possible situation of abuse to the authorities B. Call the provider, who will probably have more long-term knowledge C. Discuss the scenario with other nurses to see which approaches they have taken in similar situations in the past D. Encourage the team to have a family meeting including the parents, but not the uncle, to gather more information
D. Encourage the team to have a family meeting including the parents, but not the uncle, to gather more information Rationale: The nurse should utilize other disciplines in a team fashion and attempt to gather more facts before deciding appropriate further steps.
The nurse provides care for an older adult client who appears fully alert and oriented. As it gets later in the day, the nurse notices the client becoming increasingly confused and agitated. It would be *most* appropriate for the nurse to take which of these actions? A. Reorient the client, and then turn on the lights and television to distract the client from his confusion B. Encourage the client's alert roommate to talk with the client C. Tell the client he is at home in his own bed to get him to settle down and go to sleep D. Reorient the client, pull the shades down, shut the lights and television off, and promote a quiet environment
D. Reorient the client, pull the shades down, shut the lights and television off, and promote a quiet environment Rationale: Promoting a quiet environment decreases stimulation to prevent agitation. it also promotes the normal sleep-wake cycle, consistent with it being "later in the day."
A client diagnosed with bipolar disorder makes a sexually inappropriate comment to the nurse. The nurse should take which action? A. Ignore the comment because the client has a mental health disorder and cannot help it B. Report the comment to the nurse manager C. Ignore the comment, but tell the incoming nurse to be aware of the client's inappropriate comments D. Tell the client that it is inappropriate for clients to speak to any staff member that way
D. Tell the client that it is inappropriate for clients to speak to any staff member that way Rationale: The nurse should notify the client that this is inappropriate behavior and set up appropriate boundaries.
