At the first meeting of a group of older adults at a daycare center for the elderly, the nurse asks one of
the members what kind of things she would like to do with the group. The older women shrugs her
shoulders and says. "You tell me, you're the leader". What is the best response for the nurs...
RN 65 - Mental Health Final HESI
At the first meeting of a group of older adults at a daycare center for the elderly, the nurse asks one of
the members what kind of things she would like to do with the group. The older women shrugs her
shoulders and says. "You tell me, you're the leader". What is 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 during this time."
C. "Yes, I have been assigned to be the leader of this group. I will be here for the next 6 weeks.
D. "Yes, I am the leader. You seem angry about not being the leader yourself." - correct answersB. "Yes. I
will be leading this group. What would you like to accomplish during this time?"
Over a period of several weeks. one male participant of a socialization group at a community daycare
center for the elderly monopolizes most of the groups 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 during group meetings.
B. Remind the client to allow others in the group a chance to talk
C. Allow the group to handle the problem
D. Ask the client to join another group - correct answersAllow the group to handle the problem
An 86-year-old female client with Alzheimer's disease is wandering the busy halls of the extended care
facility and asks the nurse, "Where should I stand for the parade?" Which response is best for the nurse
to provide?
A. Anywhere you want to stand as long as you don't get hurt by those in the parade
B. You are confused because of all the activity in the hall. There is no parade
C. Let's go back to the activity room and see whats going on in there
D. Remember I told you that this is a nursing home and I am your nurse - correct answers"Let's go back
to the activity room and see whats going on in there"
Physical examination of a 6 year old reveals several bite marks in various locations on his body. X-ray
examination revealed healed fractures of the ribs. The mother tells the nurse that her child is always
having accidents. Which initial response by the nurse is most important.
A. I need to inform the health care provider about your child's tendency to be accident prone.
B. Tell me more specifically about your child's accidents
C. I must report these injuries to the authorities because they do not seem accidental.
D. Boys this age always to require more supervision and can be quite accident prone. - correct
answers"Tell me more specifically about your child's accidents."
A child is brought to the emergency room with a broken arm. Because of these injuries, the nurse
suspects the child may be a victim of abuse. When the nurse tries to give the child an injection, the child
,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 statement? The mother is
A. Regressing to an earlier behavior pattern
B. Sublimating her anger
C. Projecting her feelings onto the nurse
D. Suppressing her fear - correct answersProjecting her feelings onto the nurse
A 38-year-old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is
brought to her, she refuses to eat and tells the nurse. "i know you are trying to poison me with food."
Which response would be most important for the nurse to make?
A. I'll leave your tray here. I am available if you need anything else
B. You are not being poisoned. Why do you think someone is trying to poison you
C. No one on this unit has ever died from poisoning. You are safe here.
D. I will talk to your healthcare provider about the possibility of changing your diet - correct answersI'll
leave your tray here. I am available if you need anything else.
A 25-year-old female client has been particularly restless and the nurse finds her trying to leave the
psychiatric unit. She tells the nurse "Please let me go I must leave because the secret police are after
me." which is best for the nurse to make?
A. No one is after you. You are safe here
B. You will feel better after you have rested
C. I know you must feel lonely and frightened
D. Come with me to your room and I will sit with you - correct answersCome with me to your room and I
will sit with you
A 45-year-old male client tells the nurse he used to believe he was Jesus Christ but now he knows he is
not. Which response is best for the nurse to make?
A. Did you really believe you were Jesus Christ?
B. I think you're getting well
C. Others have had similar thoughts when under stress
D. Why did you think you were Jesus Christ? - correct answersOthers have similar thoughts when under
stress
A nurse working in the emergency room of a children hospital admits a child whose injuries could have
resulted from abuse. Which statement accurately describes the nurse's responsibility in cases of
suspected child abuse?
A. The nurse should obtain objective data such as x-rays before reporting suspicions to authorities
B. The nurse should confirm any suspicions of child abuse with the health care provider before reporting
to the authorities.
C. The nurse should report any case of suspected child abuse to the charge nurse
D. The nurse should note in the client's record any suspicions of child abuse so that a history of
suspicions can be tracked. - correct answersThe nurse should report any case of suspected child abuse
to the charge nurse
, A client who is being treated with lithium carbonate for bipolar disorder develops diarrhea, vomiting,
and drowsiness. What action should the nurse take?
A. Notify the healthcare provider. Immediately and prepare for administration of an antidote
B. Notify the healthcare provider of the symptoms prior to the next administration of the drug
C Record the symptoms as normal side effects and continue administration of prescribed dosage.
D. Hold the medication and refuse to administer additional amount of the drug - correct answersNotify
the healthcare provider of the symptoms prior to the next administration of the drug
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.. the nurse knows that the client is using which defense
mechanism
A. Sublimation
B. Identification
C. Introjection
D. Repression - correct answersIdentification
The nurse is planning the care for a 32-year-old male client with acute depression. Which nursing
intervention would best in helping this client with his depression?
A. Ensure that the client's day is filled with group activities
B. Assist the client in exploring feelings of shame, anger, and guilt
C. Allow the client to initiate and determine activities of daily living.
D. Encourage the client to explore the rationale for his depression - correct answersAssist the client in
exploring feelings of shame, anger, and guilt
An anxious client expressing a fear of people and open places is admitted to the psychiatric unit. What is
the most effective way for the nurse to assist this client?
A. Plan an outing within the first week of admission.
B. Distract her whenever she expresses her discomfort about being with others.
C. Confront her fear and discuss the possible causes of these fears.
D. Accompany her outside for an increasing amount of time each day. - correct answersAccompany her
outside for an increasing amount of time each day
A client with bipolar disorder on the mental health unit becomes loud, and shouts at one of the nurses,
"You fat tub of lard! Get something done around here!" What is the best initial action for the nurse to
take?
A. Have the orderly escort the client to his room.
B. Tell the client his healthcare provider will be notified if he continues to be verbally abusive.
C. Redirect the client's energy by asking him to tidy the recreation room.
D. Call the healthcare provider to obtain a prescription for a sedative. - correct answersRedirect the
client's energy by asking him to tidy the recreation room
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