A client with depression remains in bed most of the day, declines activities and refuses meals. Which nursing problem has the greatest priority for this client?
a.Loss of interest in diversional activity.
b.Social isolation
c.Refusal to address nutritional needs
d.Low self-esteem - Answer - C...
a client with depression remains in bed most of the day
declines activities and refuses meals which nursing problem has the greatest priority for this client
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HESI MENTAL HEALTH Q/A 2022
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HESI MENTAL HEALTH REVIEW Q/A 2022
A client with depression remains in bed most of the day, declines activities and refuses
meals. Which nursing problem has the greatest priority for this client?
a.Loss of interest in diversional activity.
b.Social isolation
c.Refusal to address nutritional needs
d.Low self-esteem - Answer - C
The nurse is preparing medications for a client with bipolar disorder and notices that the
antipsychotic medication was discontinued several days ago. Which medication should
also be discontinued?
a.Lithium (lithotabs )
b.Benztropine (Cogentin)
c.Alprazolam (Xanax)
d.Magnesium (milk of magnesia) - Answer - B
A female client request that her husband be allowed to stay in the room during the
admission assessment. While interviewing the client, the nurse notes a discrepancy
between the client's verbal and nonverbal communication. What action should the nurse
take?
a.Pay close attention and document the nonverbal messages
b.Ask the client's husband to interpret the discrepancy
c.Ignore the nonverbal behavior and focus on the client's verbal messages.
d.Integrate the verbal and nonverbal messages and interpret them as one. - Answer - A
A male client approaches the nurse with an angry expression on his face and raises his
voice, saying, "My roommate is the most selfish, self-centered, angry person I have ever
met. If he loses his temper one more time with me, I am going to punch him out!" the
nurse recognizes that the client is using which defense mechanism?
a.Denial
b.Projection
c.Rationalization
d.Splitting - Answer - B
A male client with bipolar disorder who began taking lithium carbonate five days ago is
complaining of excessive thirst, and the nurse finds him attempting to drink water from
the bathroom sink faucet. Which intervention should the nurse implement?
a.Report the client's serum lithium level to the healthcare provider
b.Encourage the client to suck on hard candy to relieve the symptoms
,c.No actions is needed since polydipsia is a common side effect
d.Tell the client that drinking from the faucet is not allowed - Answer - A
The nurse is teaching a client about the initiation of a prescribed abstinence therapy
using disulfiram (Antabuse). What information should the client acknowledge
understanding?
a.Completely abstain from heroin or cocaine use
b.Remain alcohol free from 12 hours prior to the first dose
c.Attend monthly meetings of alcoholics anonymous
d.Admit to others that he is a substance abuser - Answer - B
A male client with schizophrenia is admitted to the mental health unit after abruptly
stopping his prescription for ziprasidone (Geodon) one month ago. Which question is
most important for the nurse to ask the client
a.Have you lost interest in the things that you used to enjoy?
b.Is your ability to think or concentrate decreased?
c.How many continuous hours do you sleep at night
d.Do you hear sounds or voices that others do not hear? - Answer - D
During an annual physicalby the occupational nurse working in a corporate clinic, a
male employee tells the nurse that his high-stress job is causing trouble in his personal
life. He further explains the he often gets so angry while driving to and from work that he
has considered"getting even" with other drivers, how should the nurse respond? SATA
a."anger is contagious and could result in major confrontation"
b."Try not to let your anger cause you to act impulsively"
c."expressing your anger to a stranger could result in an unsafe"
d.It sound as if there are many situations that make you feel angry - Answer - C, D
A client who has agoraphobia (a fear of crowds) is beginning desensitization with the
therapist, and the nurse is reinforcing the process. Which intervention has the highest
priority for this client's plan of care?
a.Encourage substitution of positive thoughts for 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 - Answer - B
A male clientis 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 literally contracted position, he states that
something has made his body confort into a monster. What action should the nurse
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. -
Answer - D
A mental health worker (MHW) is caring for a client with escalating aggressive behavior.
Which action by the MHW warrants immediate intervention by the nurse?
A)Is attempting to physically restrain the client.
B)Tells the client to go to the quiet area of the unit.
C)Is using a loud voice to talk to the client.
D)Remains at a distance of 4 feet from the client. - Answer - A
A client on the mental health unit is becoming more agitated, shouting at the staff, and
pacing in the hallway. When a PRN medication is offered, the client refuses the
medication and defiantly sits on the floor in the middle of the unit hallway. What nursing
intervention should the nurse implement first?
A)Transport of the client to the seclusion room
B)Quietly approach the client with additional staff members.
C)Take other client in the area to the client lounge.
D)Administer medication to chemically restrain the client - Answer - C
A client is admitted to the mental health unit and reports taking extra antianxiety
medication because, "I'm so stressed out. I just wanted to go sleep" the nurse 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 talk. Nothing matters anymore." - Answer - D
A male hospital employee is pushed out of 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
nurse. 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 - Answer - C
The nurse documents the mental status of a female client who has been hospitalized for
several days by court order. The client state, "I don't need to be here" and tells the
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