, HESI RN MENTAL HEALTH 53 Q&A
1. When caring for an older client, the nurse observes multiple bruises in over the client’s legs, arms,
back, and gluteal areas. When the client contact, the nurse suspects elder abuse. What action
should the nurse?
Measure and document size, shape and color of the bruised areas.
2. A client who is homeless is diagnosed with schizophrenia and admitted on an involuntary basis to e
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 nurse take?
Administer a long acting antipsychotic medication so that the client can be discharged to a
shelter.
3. After receiving treatment for anorexia, a student asks the school nurse for permission to work in the
school cafeteria as part of the school’s wok study program. What action should the nurse take?
Recommend assignment to the receptionist’s office.
4. 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 to ask this client?
Have you taken any medication for erectile dysfunction?
5. On admission to the mental health unit, a client diagnosed with schizophrenia tells the nurse that he
is the son of God. Based on this statement, which intervention should the nurse include in this
client’s plan of care?
Confront his delusion as not consistent with reality.
6. The nurse on the day shift receives report about a client with depression who was in bed most of
the weekend. The nurse walks into the client’s room in the morning and finds the client in bed.
What intervention I best for the nurse to implement?
Assist the client to get out of bed and involved in an activity.
7. Which client information indicates the need for the nurse to use the CAGE questionnaire during the
admission interview?
Describes self as a social drinker who drinks alcoholic beverages daily.
8. A female client admitted to the mental health unit stats to shout and scream at the nurse. What is
he best approach for the nurse to take? Stay quietly with the client.
9. A woman is brought to the psychiatric clinic by her husband. He reports that his wife is reluctant to
leave home because of what she describes as a fear of open places and crows. Which nursing
problems applies to the client’s behavior?
Anxiety related to real or perceived threat to physical integrity.
10. A client is receiving benztropine mesylate (Cogentin) for drug-induced extrapyramidal syndrome
(EPS). Which finding indicates that the RN should further evaluate the client? Presence of a dry
mouth.
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