1. 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. His temperature is 100.0 F, pulse is 100, and blood pressure is
142/100...
1. 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. His temperature is 100.0 F, pulse is 100, and blood pressure is
142/100. The nurse plans to give the client lorazepam (Ativan) based on which priority nursing
diagnosis?
a. Risk for injury related to suicidal ideation.
b. Risk for injury related to alcohol detoxification.
c. Knowledge deficit related to ineffective coping.
d. Health seeking behaviors related to personal crisis.
2. 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?
a. Obtain objective data such as x-rays before reporting suspicions.
b. Confirm suspicions of abuse with the physician.
c. Report any case of suspected child abuse.
d. Document injuries to confirm suspected abuse.
3. 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?
a. She is regressing to an earlier behavior pattern.
b. She is sublimating her anger.
c. She is projecting her feelings onto the nurse.
d. She is suppressing her fear.
4. A client, who is on a 30-day commitment to a drug rehabilitation unit, asks the nurse if he can go
for a walk on the grounds of the treatment center. When he is told that his privileges do not
include walking on the grounds, the client becomes verbally abusive. Which approach should the
nurse take?
a. Ask the staff to escort the client to his room.
b. Have the client ask his physician to change his privileges.
c. Remind the client of the importance of following the rules.
d. Disregard the client's inappropriate verbal outburst.
5. 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?
a. Perphenazine (Trilafon).
b. Diphenylhydramine (Benadryl).
c. Chlordiazepoxide (Librium).
d. Isocarboxazid (Marplan).
6. 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. Excessive CNS stimulation will be reduced.
d. Client's level of consciousness will increase.
7. 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 which disorder?
a. Claustrophobia.
b. Acrophobia.
, HESI: Psychiatric-Mental Health Nursing 2
c. Agoraphobia.
d. Necrophobia.
8. 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?
a. Encourage the client's self motivation by asking her to pass trays for the rest of the week.
b. Provide an additional challenge by asking the client to help feed the older clients.
c. Suggest another way for this client to participate in the unit's activities.
d. Tell the client that hospital guidelines allow only staff to pass the trays.
9. A female client with depression attends a 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?
a. "Can your case manager take you to your appointments?"
b. "Take your medication for anxiety before you ride the bus."
c. "Let's talk about what happens when you feel very anxious."
d. "What are some ways that you can cope with your anxiety?"
10. 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 which condition?
a. Dissociative disorder.
b. Obsessive-compulsive disorder.
c. Panic disorder.
d. Post-traumatic stress syndrome.
11. At the first meeting of a group of older adults at a day care 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 would be the best response
for the nurse to make?
a. "Yes, I am the leader today. Would you like to be the leader tomorrow?"
b. "Yes, I will be leading this group. What would you like to accomplish?"
c. "Yes, I have been assigned to lead this group. I will be here for the next six weeks."
d. "Yes, I am the leader. You seem angry about not being the leader yourself."
12. Over a period of several weeks, one male client 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?
a. Talk to the client outside the group about his behavior.
b. Ask the client to give others a chance to talk.
c. Allow the group to handle the problem.
d. Ask the client to join another group.
13. A client in the critical care unit who has been oriented suddenly becomes disoriented and fearful.
Assessment of vital signs and other physical parameters reveal no significant changes, and the
nurse formulates the diagnosis: "Confusion related to ICU psychosis." Which intervention is
best to implement based on this client's behavior?
a. Move all machines away from the client's bedside at once.
b. Allay fears by teaching the client about disease etiology.
c. Cluster care to allow for brief rest periods during the day.
d. Encourage visitation by the client's family members.
14. A client on the psychiatric unit appears to imitate a certain nurse on the unit. The client seeks out
this particular nurse and imitates her mannerisms. Which defense mechanism does the nurse
recognize in this client?
a. Sublimation.
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