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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 the...
HESI Mental Health RN Questions And Answers From V1-V3 Test Banks And
Actual Exams Rated A+
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, 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 self-esteem 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 client is admitted to the mental health unit and reports 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.
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?
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.
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?
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