EXAM ELABORATIONS HESI RN MENTAL HEALTH
V1& V3 ALL TOGETHER EXAM ELABORATIONS
HESI RN
HESI MENTAL HEALTH RN V1-V3 2019 TEST BANKS (ALL
TOGETHER)
A client with depression remains in bed most of the day, and
declines activities. Which nursing problem has the greatest
priority for this client?
A. Loss of interest in diversional activity.
B. Social isolation.
C. Refusal to address nutritional needs.
D. Low self-esteem.
The RN is preparing medications for a client with bipolar
disorder and notices that the client discontinued
antipsychotic medication for several days. Which medication
should also be discontinued?
a. Lithium. (Lithotabs)
b. Benzotropine (Cogentin).
c. Alprazolam (Xanax).
d. Magnesium (Milk of Magnesia).
A female client requests that her husband be allowed to stay
in the room during the admission assessment. When
interviewing the client, the RN notes a discrepancy between
the client’s verbal and nonverbal communication.
What action does the RN take?
A. Pay close attention and document the nonverbal messages.
B. Ask the client’s husband to interpret the discrepancy.
C. Ignore the nonverbal behavior and focus on the
client’s verbal messages.
D. Integrate the verbal and nonverbal messages and
interpret them as one.
A male client approaches the RN with an angry expression on
his face and raises his voice, saying “My roommate is the
most selfish, self-centered, angry person I have ever met. If
he loses his temper one more time with me, I am going to
punch him out!” The RN recognizes that the client is using
which defense mechanism?
A.
Denial. B.
Projection.
C. Rationalization.
D. Splitting.
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A male client with bipolar disorder who began taking lithium
carbonate five days ago is complaining of excessive thirst,
and the RN finds him attempting to drink water from the
bathroom sink faucet. Which intervention should the RN
implement?
A. Report the client’s serum lithium level to the HCP.
B. Encourage the client to suck on hard candy to relieve the
symptoms.
C. No action is needed since polydipsia is a common side
effect.
D. Tell the client that drinking from the faucet is not allowed.
The RN is teaching a client about the initiation of the prescribed
abstinence therapy using disulfiram (Antabuse). What
information should the client acknowledge understanding?
A. Completely abstain from heroin or cocaine use.
B. Remain alcohol free for 12 hours prior to the first dose.
C. Attend monthly meetings of alcoholics anonymous.
D. Admit to others that he is a substance user.
A male client with schizophrenia is admitted to the mental
health unit after abruptly stopping his prescription for
ziprasidone (Geodon) one month ago. Which question is
most important for the RN to ask the client?
A. Have you lost interest in the things that you used to enjoy?
B. Is your ability to think or concentrate decreased?
C. How many continuous hours do you sleep
at night? D. Do you hear sounds or voices
that others do not hear?
During an annual physical by the occupational RN working in
a corporate clinic, a male employee tells the RN that is highstress job is causing trouble in his personal life. He further
explains that he often gets so angry while driving to and
from work that he has considered “getting even” with other
drivers. How should the RN respond?
A. “Anger is contagious and could result in major
confrontation.”
B. “Try not to let your anger cause you to act impulsively.”
C. “Expressing your anger to a stranger could result
in an unsafe situation.”
D. “It sounds as if there are many situations that make you
feel angry.”
A client who has agoraphobia (a fear of crowds) is beginning
desensitization with the therapist, and the RN is reinforcing
the process. Which intervention has the highest priority for
this client’s plan of care?
A. Encourage substitution of positive thoughts and
negative ones. B. Establish trust by providing a calm,
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safe environment.
C. Progressively expose the client to larger crowds.
D. Encourage deep breathing when anxiety escalates in a
crowd.
Which nursing actions are likely to help promote the selfesteem of a male client with modern depression?
A. Ask the client what his long term goals are.
B. Discuss the challenges of his medical condition.
C. Include the client in determining treatment
protocol. D. Encourage the client to engage in
recreational therapy.
E. Provide opportunities for the client to discuss his concerns.
A male client is admitted to the psychiatric unit for recurrent
negative symptoms of chronic schizophrenia and medication
adjustment of Risperidone (Risperdal). When the client walks
to the nurse’s station in a laterally contracted position, he
states that something has made his body contort into a
monster. What action should the RN take?
A. Medicate the client with the prescribed
antipsychotic thioridazine (Mellaril).
B. Offer the client a prescribed physical therapy hot
pack for muscle spasms.
C. Direct client to occupational therapy to distract him
from somatic complaints.
D. Administer the prescribed anticholinergic benztropine
(Cogentin) for dystonia.
A mental health worker is caring for a client with escalating
aggressive behavior. Which action by the MHW warrant
immediate intervention by the RN?
A. Is attempting to physically restrain the patient.
B. Tells the client to go to the quiet area of the unit.
C. Is using a loid voice to talk to the client.
D. Remains at a distance of 4 feet from the client.
A client on the mental health unit is becoming more agitated,
shouting at the staff, and pacing in the hallway. When the
PRN medication is offered, the client refuses the medication
and defiantly sits on the floor in the middle of the unit
hallway. What nursing intervention should the RN implement
first?
A. Transport of the client to the seclusion room.
B. Quietly approach the client with additional
staff members. C. Take other clients in the area
to the client lounge.
D. Administer medication to chemically restrain the patient.
A client is admitted to the mental health unit and reports
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taking extra antianxiety medication because, “I’m so
stressed out. I just want to go to sleep.” The RN should
plan one-on-one observation of the client based on which
statement?
A. “What should I do? Nothing seems to help.”
B. “I have been so tired lately and needed to sleep.”
C. “I really think that I don’t need to be here.”
D. “I don’t want to walk. Nothing matters anymore.”
A male hospital employee is pushed out the way by a female
employee because of an oncoming gurney. The pushed
employee becomes very angry and swings at the female
employee. Both employees are referred for counseling with
the staff psychiatric RN. Which factor in the pushed
employee’s history is most related to the reaction that
occurred?
A. Is worried about losing his job to a woman.
B. Tortured animals as a child.
C. Was physically abused by his mother.
D. Hates to be touched by anyone.
The RN documents the mental status of a female client who
has been hospitalized for several days by court order. The
client states, “I don’t need to be here” and tells the RN that
she believes the television talks to her. The RN should
document these assessment findings in which section of the
mental status exam/
A. Level of
concentration. B.
Insight and
judgement.
C. Remote memory.
D. Mood and affect.
A client is admitted to the mental health unit reports shortness
of breath and dizziness. The client tells the RN, “I feel like I’m
going to die”. Which nursing problem should the RN include in
this client’s plan of care?
A. Mood
disturbance. B.
Moderate anxiety.
C. Altered thoughts.
D. Social isolation.
A female client who is wearing dirty clothes and has foul body
odor, comes to the clinic reporting feeling scared because
she is being stalked. What action is most important for the
RN to take?
A. Offer the client a safe place to relax before interviewing
her.
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B. Ask the client to describe why she is being stalked.
C. Recommend that the client talk with a social worker.
D. Assure the client that the HCP will see her today.
The RN leading a group session of adolescent clients gives the
members a handout about anger management. One of the
male clients is fidgety,interrupts peers when they try and talk,
and talks about his pets at home. What nursing action is best
for the RN to take?
A. Explore the client’s feelings about his pets and home life.
B. Encourage his peers to help involve him in the activity.
C. Give the client permission to leave and return in
10 minutes. D. Redirect him by encouraging him
to read from the handout.
A male adolescent was admitted to the unit two days ago for
depression. When the mental health RN tries to interview the
client to establish rapport, he becomes very irritated and
sarcastic. Which action is best for the RN to take?
A. Report the behavior to the next shift.
B. Offer to play a game of cards with the client.
C. Document the behavior in the chart.
D. Plan to talk with the client the next day.
A male adult is admitted because of an acetaminophen
(Tylenol) overdose. After transfer to the mental health unit,
the client is told he has liver damage. Which information is
most important for the nurse to include in the client's
discharge plan?
A. Do not take any over the counter meds.
B. Eat a high carb, low fat, low protein diet.
C. Call the crisis hotline if feeling lonely.
D. Avoid exposure to large crowds.
After receiving treatment for anorexia, a student asks the school
RN for permission to work in the school cafeteria as part of the
school’s work study program. What action should the RN take?
A. Refer the student to a psychiatrist for further
discussion. B. Recommend assignment to the
receptionist’s office.
C. Suggest that student work in the athletic department.
D. Determine the parent’s opinion of the work assignment.
The Rn accepts a transfer to the metal health unit and
understands that the client is distractible and is exhibiting a
decreased ability to concentrate. The RN only has 15
minutes to talk to the client. To develop treatment plan for
this client, which assessment is most important for the RN to
obtain?
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A. Motivation of treatment.
B. History of substance use.
C. Medication compliance.
D. Mental status examination.
A male client who recently lost a loved one arrives at the
mental health center and tells the RN he is no longer
interested is his usual activities and has not slept for several
days. Which priority nursing problem should the RN include in
the client’s plan of care?
A. Risk for
suicide. B. Sleep
deprivation.
C. Situational low self-esteem.
D. Social isolation.
A male client with long history of alcohol dependency arrives
in the emergency department describing the feelings of bugs
crawling on his body. His blood pressure is 170/102, his pulse
rate is 110 bpm, and is blood alcohol level is 0mg/dL. Which
prescription should the RN administer?
A. Haloperidol (Haldol).
B. Thiamine (Vitamin B1).
C. Diphenhydramine
(Benadryl). D. Lorazepam
(Ativan).
A client who refuses antipsychotic medications disrupts group
activities, talks with nonsensical words and wanders into
client’s rooms. The RN decides that the client needs constant
observation based on which of these assessment findings?
A. Wanders into the clients rooms.
B. Refuses antipsychotic medications.
C. Talks with nonsensical words.
D. Disrupts group activities.
A client with schizophrenia explains that she has 20
children and then very seriously points to the RN and
explains that she is one of them. What is the most
therapeutic response for the RN to provide/
A. “Let’s go ask another RN is this is
true.” B. “My name tag shows that I
am a RN here.”
C. “I can’t possibly be one if your children.”
D. “I know that you don’t have 20 children.”
A high school girl reveals to the high school RN that she has
been engaging in self-induced vomiting as weight-control
measure. Which initial assessment should the RN focus on
with this adolescent?
A. National percentile of weight and height.
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B. Frequency of bingeing and purging behaviors.
C. Perceptions of family and social relationships.
D. School grades and extracurricular activities.
Narcan was administered to an adult client following a
suicide attempt with an overdose of hydrocodone bitartrate
(Vicodin). Within 15 minutes, the client is alert and oriented.
In planning nursing care, which intervention has the highest
priority at this time?
A. Encourage the client to increase fluid intake.
B. Obtain the client’s serum Vicodin level.
C. Observe the client for further narcotic effects.
D. Determine the client’s reason for attempting suicide.
Following surgery, a male client with antisocial personality
disorder frequently requests that a specific RN be assigned
to is care and is belligerent when another RN is assigned.
What action should the charge RN implement?
A. Reassure the client that his request will be met whenever
possible.
B. Advise the client that assignments are not based
on the client’s request.
C. Ask the client to explain why he constantly requests the RN.
D. Encourage the client to verbalize his feelings about the RN.
When preparing to administer a prescribed medication to a
homeless male at a community clinic, the client tells the RN
that he usually takes a different dosage. What action should
the RN take?
A. Tell him to take the medication then verify the
dosage at the next healthcare team meeting.
B. Withhold the medication until the dosage can be confirmed.
C. Inform him that he may refuse the medication and
document whether or not he takes it.
D. Explain to the client that the dosage has been changed.
The nurse orients a female client with depression to the new
room on the mental health unit. The client states “It seems
strange that I don’t have a T.V in my room.” Which statement
would be best for the RN to provide?
A. “You can watch T.V as much as you want outside of your
room.”
B. “Sometimes clients feel like the T.V is sending
them messages.” C. “It’s important to be out of you
room and talking to others.”
D. “Watching T.V is a passive activity and we want you to be
active.”
A client admitted with a closed head injury after a fall has a
blood alcohol level of 0.28 (28%) and is difficult to arouse.
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Which intervention during the first 6 hours following
admission should the RN identify as the priority?
A. Give lorazepam (Ativan) PRN for signs of withdrawal.
B. Administer disulfiram (Antabuse) immediately.
C. Place in a side lying position with head of bed elevated.
D. Provide thiamine and folate supplements as prescribed.
The RN is completing the admission assessment of
an underweight adolescent who is admitted to a
psychiatric unit with a diagnosis of depression. Which
finding requires notification to the HCP?
A. Potassium level of 2.9 mEq/dl.
B. Blood pressure of 110/70 mmHg.
C. WBC of 10,000mm^3.
D. Body mass index of 21.
The Rn is planning client teaching for a 35-year-old client with
alcoholic cirrhosis. Which self-care measure should the RN
emphasize for the client’s recovery?
A. Support group meetings.
B. Vitamin B and multivitamin supplements.
C. Diet with adequate calories and
protein. D. Alcohol abstinence.
A teenager has lost 20 pounds in the last three months is
admitted to the hospital with hypotension and tachycardia.
The client reports irregular menses and hair loss. Which
intervention is most important for the RN to include in the
clients plan of care?
A. Implement behavioral modification
therapy. B. Initiate caloric and
nutritional therapy.
C. Evaluate the client for low self-esteem.
D. Record daily weights and graft trend.
While interviewing a client, the nurse takes notes to assist
with accurate documentation later. Which statement is most
accurate regarding note- taking during an interview?
A. The client’s comfort level is increased when the RN
breaks eye contact to take notes.
B. The interview process is enhanced with note taking
and allows the client to speak at a normal pace.
C. Taking notes during an interview is a legal obligation of
examining RN.
D. The RN’s ability to directly observe the
client’s non-verbal communication is limited
with note taking.
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A client is receiving substitution therapy during withdrawal
from benzodiazepines. Which expected outcome statement
has the highest priority when planning nursing care?
a. Client will not demonstrate cross addiction.
b. Co-dependent behaviors will be decreased.
c. CNS stimulation will be reduced.
d. Client's level of consciousness will increase.
A client who is being treated with lithium carbonate for
manic depression begins to develop diarrhea, vomiting,
and drowsiness. What action should the nurse take?
a. Notify the physician immediately and force fluids.
b. Prior to giving the next dose, notify the
physician of the symptoms.
c. Record the symptoms and continue medication as
prescribed.
d. Hold the medication and refuse to administer
additional amounts of the drug.
While caring for an older client, the RN observes multiple
bruises in Over the client’s legs, arms, back, and gluteal
areas. When the client Contact, the RN suspects elder
abuse. What action should the RN take?
A. Report family conversations and anger towards
the client when visiting.
B. Ask the client specific questions about someone causing
the bruising.
C. Question the family members and caregiver how the
bruising occurred. D. Measure and document size, shape
and color of the bruised areas.
The RN is performing intake interviews at a psychiatric clinic.
A female client with a known history of drug abuse reports
that she had a heart attack four years ago. Use of which
substance places the client at highest risk for myocardial
infarction?
A. Benzodiazepine
B. Alcohol
C. Methamphetamine
D. Marijuana
After receiving treatment for anorexia, a student asks the school
RN for permission to work in the school cafeteria as part of the
school’s work study program. What action should the RN take?
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A. Suggest that the student work in the athletic department.
B. Determine the parent’s opinion of the work assignments.
C. Refer the student to a psychiatrist for further
discussion. D. Recommend assignment to the
receptionist’s office.
A client who is homeless is diagnosed with schizophrenia and
admitted on an involuntary basis to a mental health hospital 4
days ago. The client stopped taking prescribed antipsychotic
drugs approximately one month ago. Since hospitalization the
client continues to have poor judgment and refuses all
medications. What action should the RN take?
A. Encourage the client to stay in the hospital so the client
does not have to be homeless.
B. Provide the client with medication if the client
presents an imminent risk to self and others.
C. Administer a long acting antipsychotic medication so
that the client can be discharged to a shelter.
D. Describe to the client treatment options provided at
the community mental health clinics.
A male client comes to the emergency center because he has
an erection that will not resolve. The client reports that he is
taking trazodone (Desyrel) for insomnia. Which information is
most important for the nurse ask the client?
A. When was the last time you drank alcoholic
beverage? B. Have you taken any medications
for erectile dysfunction?
C. Are you having any other sexual dysfunctions or problems?
D. Do you have a history of angina or high blood pressure?
On admission to the mental health unit, a client diagnosed
with schizophrenia tells the RN that he is the son of god.
Based on this statement, which intervention should the RN
include in this client’s plan of care?
A. Lead the client by his arm to the seclusion room.
B. Ensure the client’s environment is safe.
C. Schedule activity therapy twice a week.
D. Confront his delusion as not consistent with reality.
The RN on the day shift receive report about a client with
depression who was in bed most of the weekend. The RN
walks into the client’s room in the morning and finds the
client in bed. What intervention is best for the RN to
implement?
A. Monitor the client’s appetite and pattern of sleep
Version | Latest |
Category | HESI |
Release date | 2021-09-08 |
Pages | 49 |
Language | English |
Comments | 0 |
High resolution | Yes |
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