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HESI MENTAL HEALTH RN 55 QUESTIONS

1. A client with paranoia is admitted to the mental health unit and immediately

goes to the corner of the room and sits quietly without communicating. In

approaching the client, what intervention should the nurse implement first?

• Explain the nurse's role to the client.

2. Client treated with lithium for bipolar develops diarrhea, vomiting and

drowsiness, what action should the nurse do

• Notify HCP of the symptoms prior to the next admin of the drug

3. A mental health worker (MHW) is caring for a client with escalating aggressive

behavior, which action by the MHW warrants immediate intervention by the

nurse?

• Is attempting to physically restrain the client.

4. A woman who is bipolar is wearing low cut blouse, and skirt with no underwear,

what does nurse do?

• Walk her to room and help her pick out something more appropriate

5. An older man who recently got divorced and is 2 years sober, and an alcoholic

loves God. He loves kids also. What should nurse ask at his initial interaction?

• What is your biggest concern?

6. A woman who is diagnosed with breast cancer becomes dependent and asks

family members if they can do ADL's that she is fully capable of doing. What is

the reason for this behavior?

• Its expected; regression is a naturalstart for recovery

7. Patient having to get treated for benzo diazepam and methadone overdose.

What do you use?

• Narcan

8. Patient watching TV starts talking loud to himself. The nurse comesin and can't

distract him so turns down the TV. What should the nurse do then?

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• Move client to quieter room

9. In group therapy the charge nurse notices a client increasing to severe levels of

anxiety. What should the nurse do?

• Talk in a calm, approaching manner

10. A chronic depressed older man refuses to leave his room. His family moved

away to a further location so they're not able to visit him as much. What

approach should the nurse take with this man?

• May I lay with you for a little?

11. Patient who is really depressed and won't talk or communicate, later is

energetic and talkative. What should the nurse do?

• Closely monitor the patient (could be suicidal)

12. Patient who had generalized anxiety disorder on Xanax long-term. What is

the outcome?

• Importance of not quickly stopping the drug

13. A mother has a 9-month-old baby with mental issues and growth issues. The

mother comes in and says she's depressed because she’ll never have a normal

baby. What should the nurse say?

• Have you had any thoughts of harming your baby or yourself?

14. Lithium level 1.5. What do you tell the client who had a recent suicide

attempt afterseeing him become very anxious after hearing his Lithium levels?

• drink 2-3L of water in 24 hours

15. Woman comes into ED having been raped by her date. What should the

nurse document?

• document she stated "I was raped by my date"

16. Which patient would require CAGE assessment?

• Alcohol patient, cut down, annoyed, guilty, eye opener

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