1. While caring for an older client, the nurse observes multiple bruises over the client’s legs, arms, back, and gluteal areas. When the client contact, the nurse suspects elder abuse. What action should the nurse indicate?
Measure and document size, shape and color of the bruised areas.
2. A ...
HESI Mental Health Exam
1. While caring for an older client, the nurse observes multiple bruises over the client’s legs, arms,
back, and gluteal areas. When the client contact, the nurse suspects elder abuse. What action
should the nurse indicate?
➢ Measure and document size, shape and color of the bruised areas.
2. A client who is homeless is diagnosed with schizophrenia and admitted on an involuntary basis to e
mental health hospital 4 days ago. The client stopped taking prescribed antipsychotic drugs
approximately one month ago. Since hospitalization the client continues to have poor judgment
and refuses all medications. What action should the nurse take?
➢ Administer a long acting antipsychotic medication so that the client can be discharged to
a shelter. ?
3. After receiving treatment for anorexia, a student asks the school nurse for permission to work in
the school cafeteria as part of the school’s wok study program. What action should the nurse take?
➢ Recommend assignment to the receptionist’s office.
4. A male client comes to the emergency center because he has an erection that will not resolve.
The client reports that he is taking trazodone (desyrel) for insomnia. Which information is most
important for the nurse to ask this client?
➢ Have you taken any medication for erectile dysfunction?
5. On admission to the mental health unit, a client diagnosed with schizophrenia tells the nurse that
he is the son of God. Based on this statement, which intervention should the nurse include in this
client’s plan of care?
➢ Confront his delusion as not consistent with reality.
6. The nurse on the day shift receives report about a client with depression who was in bed most of
the weekend. The nurse walks into the client’s room in the morning and finds the client in bed.
What intervention I best for the nurse to implement?
➢ Assist the client to get out of bed and involved in an activity.
7. Which client information indicates the need for the nurse to use the CAGE questionnaire during
the admission interview?
➢ Describes self as a social drinker who drinks alcoholic beverages daily.
8. A female client admitted to the mental health unit stats to shout and scream at the nurse. What is
he best approach for the nurse to take?
➢ Stay quietly with the client.
9. A woman is brought to the psychiatric clinic by her husband. He reports that his wife is reluctant
to leave home because of what she describes as a fear of open places and crows. Which nursing
problems applies to the client’s behavior?
➢ Anxiety related to real or perceived threat to physical integrity.
10. A client is receiving benztropine mesylate (Cogentin) for drug-induced extrapyramidal
syndrome (EPS). Which finding indicates that the RN should further evaluate the client?
➢ Presence of a dry mouth.
11. A male client in the mental health unit is guarded and vaguely answers the nurse’s questions. He
isolates in his room and sometimes opens the door to peek into the hall. Which problem can the
RN anticipate?
➢ Delusions of persecution.
This study source was downloaded by 100000829219024 from CourseHero.com on 08-22-2022 09:22:25 GMT -05:00
A client with depression remains in bed most of the day, and
declines activities. 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.
The nurse is preparing medications for a client with bipolar disorder
and notices that the client discontinued antipsychotic medication for
several days. Which medication should also be discontinued?
a. Lithium. (Lithotabs)
b. Benzotropine (Cogentin).
c. Alprazolam (Xanax).
d. Magnesium (Milk of Magnesia).
A female client requests that her husband be allowed to stay in the
room during the admission assessment. When interviewing the
client, the RN notes a discrepancy between the client’s verbal and
nonverbal communication.
What action does the RN 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.
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.
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?
This study source was downloaded by 100000829219024 from CourseHero.com on 08-22-2022 09:22:25 GMT -05:00
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