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MENTAL HESI V2 2021.
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Stuvia.com - The Marketplace to Buy and Sell your Study MaterialMENTAL HESI V2 2021
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MENTAL HESI 2
1. A male employee who is assessed weekly in the employee clinic for blood pressure
because of a history of hypertension tells the nurse that he is so upset with one of his
co-workers that he would like to shoot him. What action should the nurse take first?
a.) Determine if the client has a weapon available for use.
b.) Inform the health care provider of the threat to harm a co-worker.
c.) Notify security of the client’s intention to harm a co-worker.
d.) Have the employee escorted to a mental health facility.
2. A male client who is participating in an anger management assignment asks if he can
make a leather belt in occupational therapy. The client begins pounding the leather
vigorously with a mallet to imprint designs on the belt. What defense mechanism is
the client using?
a.) Sublimation.
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b.) Suppression.
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c.) Regression.
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d.) Compensation.
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3. A 20-year-old female client with schizophrenia is scheduled to receive risperidone
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(Risperdal) 2mg at bedtime. When the nurse attempts to administer the medication,
the client states. “I am not going to take that medicine, and you can’t make me.” What
action should the nurse take?
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a.) Administer the medication via a nasogastric tube.
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b.) Substitute an injectable form of the medication.
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c.) Encourage the client to take the medicine because it will help her sleep.
d.) Document in the client’s record that the medication was refused.
4. An adult female client tells the nurse that though she is afraid her abusive boyfriend
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might one day kill her, she keeps hoping that he will change. What action should the
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nurse take first?
a.) Discuss treatment options for abusive partners.
b.) Explore client’s readiness to discuss the situation.
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c.) Determine the frequency and type of client’s abuse.
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d.) Report the finding to the police department.
5. A male client with bipolar disorder has not slept or eaten in four days. He paces and
becomes increasingly agitated and loud while the nurse talks to his spouse. What
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intervention is the best for the nurse to implement at this time?
a.) Move to a quiet area and provide peanut butter with crackers.
b.) Walk with the client to the cafeteria and star as he eats lunch.
c.) Request a full lunch tray from the dietary department.
d.) Encourage the spouse to eat lunch with the client.
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6. The nurse asks a female client with a borderline personality disorder, “How do you feel
about your children not coming to visit this weekend?” The client looks out the
window and replies, “I really don’t care.” Which response is best for the nurse to
provide?
a.) “I noticed you were looking out the window when discussing your feelings.”
b.) “I think you’re lying and it bothers you that your children aren’t coming.”
c.) “I think you should discuss your children not coming in the group meeting.”
d.) “Why do you think your children didn’t want to come visit you this weekend?”
7. What is the most important goal of care for a client diagnosed with generalized
anxiety disorder (GAD) who has been taking the benzodiazepine alprazolam (Xanax)
long-term? The client will
a.) Describe a decrease in anxiety using a 1 to 10 anxiety scale.
b.) State the importance of not abruptly stopping the medication.
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c.) Not experience dizziness, lightheadedness, or sedation.
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d.) Attend scheduled individual and group therapy sessions.
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8. The nurse is performing intake interviews at a psychiatric clinic. A female client with a
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known history of drug abuse reports that she has a heart attack four years ago. Use of
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which substance abuse places the client at highest risk for myocardial infarction.
a.) Benzodiazepine
b.) Marijuana
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c.) Methamphetamine
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d.) Alcohol
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9. During a one-to-one session with the nurse, a female client who has been admitted for
chronic depression and attempted suicide discloses her experience of sexual
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promiscuity and prostitution. When the nurse asks the client if she was ever sexually
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abused as a child, the client says, “I don’t remember, but my mother ran my father off
when I was five.” The nurse should recognize that the client may be using which
defense mechanism?
a.) Denial
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b.) Projection
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c.) Regression
d.) Repression
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10. A client who refuses antipsychotic medications disrupts group activities, talks with
nonsensical words and wanders into client’s room. The nurse decides that the client
needs constant observation based on which of these assessment findings?
a.) Disrupts group activities.
b.) Wanders into the client’s rooms.
c.) Talks with nonsensical words.
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d.) Refuses antipsychotic medications.
11. A women is brought to the psychiatric clinic by her husband who reports that his wife
is reluctant to leave home because of what she describes as fear of open places and
crowds. What is the best nursing diagnosis for this client?
a.) High risk for injury related to chronic depression.
b.) Anxiety related to poor self-image.
c.) Ineffective individual coping.
d.) High risk for injury related to isolation.
12. The atypical antipsychotic ziprasidone (Geodon) is prescribed for a client with a
medical diagnosis of schizophrenia. After the client has been taking the medication for
two weeks, the nurse assesses the drug’s effectiveness. Which client report suggests
that the medication is helpful?
a.) Is feeling less depressed?
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b.) Sleeps better at night.
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c.) The voices are quieter.
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d.) Nervousness has decreased.
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13. A male college student brings his roommate to the campus clinic because the
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roommate has been talking to someone who is not present. The client tells the nurse
that the voices are saying, “kill kill.” What question should the nurse ask the client
next?
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a.) “When did these voices begin?”
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b.) “Have you taken any hallucinogens?”
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c.) “Are you planning to obey the voices?”
d.) “Do you believe the voices are real?”
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14. A male client is admitted to the psychiatric unit for recurrent negative symptoms of
chronic schizophrenia and medication adjustment of risperidone (Risperdal). When the
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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 nurse
take?
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a.) Medicate the client with the prescribed PRN antipsychotic trifluoperazine (Stela
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zine).
b.) Offer the client a prescribed physical therapy treatment of hot pack for muscle
spasms.
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c.) Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia.
d.) Direct the client to occupational therapy to distract him from somatic complaints.
15. The nurse on the evening shift received report that a client is scheduled for
electroconvulsive treatment (ECT) in the morning. Which interventions should the
nurse implement the evening before the scheduled ECT?
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