HESI EXIT MENTAL HEALTH TEST BANK /MENTAL HEALTH HESI EXIT TEST BANK REAL EXAM QUESTIONS AND CORRECT ANSWERS|AGRADE
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HESI EXIT
HESI EXIT MENTAL HEALTH TEST BANK /MENTAL HEALTH HESI EXIT TEST BANK REAL EXAM QUESTIONS AND CORRECT ANSWERS|AGRADE
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A 13-year-old boy who recently was suspended from school for consistently bullying other children is brought to the pediatric mental health clinic by his mother. The child ...
HESI EXIT MENTAL HEALTH TEST BANK /MENTAL
HEALTH HESI EXIT TEST BANK REAL EXAM
QUESTIONS AND CORRECT ANSWERS|AGRADE
A 13-year-old boy who recently was suspended from school for consistently bullying
other children is brought to the pediatric mental health clinic by his mother. The child is
assessed by the psychiatrist and referred to a psychologist for psychological testing.
The day after the tests are completed, the mother returns to the clinic and asks the
nurse for results of the tests. The nurse should: - Answer-Refer the mother to the
psychiatrist.
/.A 15-year-old girl is brought to the high school health office by two of her friends, who
report, "We think she just took a handful of pills." The adolescent appears alert and
refuses to speak. The school nurse's initial response should be to: - Answer-Ask the
adolescent whether she took any pills.
/.A 23-year-old woman is admitted to a psychiatric unit after several episodes of
uncontrolled rage at her parents' home, and borderline personality disorder is
diagnosed. While watching a television newscast describing an incident of violence in
the home, the client says, "People like that need to be put away before they kill
someone." The nurse concludes that the client is using: - Answer-Projection
/.A 25-year-old man is admitted to the inpatient psychiatric unit. He is angry and refuses
to take his prescribed medications at bedtime. He has been agitated and had several
verbal altercations with other clients earlier in the evening. The best nursing response to
this situation is: - Answer-Educating him on the reasons for and benefits of taking the
medication but not giving it to him if he continues to refuse the medication
/.A 3-year-old child is brought to the emergency department by the mother, who reports
that her child fell down the stairs and sustained injuries to the right arm and leg. During
the physical assessment the nurse identifies a number of old bruises on the child's
back, buttocks, and upper arms. What should the nurse say to the child to obtain
additional information? - Answer-"Show me how you fell down the stairs."
/.A 34-year-old woman who was sexually assaulted is examined in the emergency
department within 2 hours of the assault. During assessment she freely discusses the
incident, her past psychiatric history, and her past sexual history with the sexual assault
nurse examiner (SANE). Which information documented by the nurse indicates that the
nurse needs more teaching about appropriate charting? - Answer-Details of the client's
sexual history
/.A child has been hospitalized repeatedly for illnesses of unknown origin. Finally the
health care provider makes the diagnosis of Munchausen syndrome by proxy. What is
,the most therapeutic approach by the nurse to the involved parent? - Answer-Open
communication
/.A child in the first grade is murdered, and counseling is planned for the other children
in the school. What should a nurse identify first before assessing a child's response to a
crisis? - Answer-Developmental level of the child
/.A client arrives at the clinic and tells the nurse about various aches and pains since
her spouse's death 3 months ago. The client appears depressed and tense. What is the
initial nursing intervention? - Answer-Facilitating a discussion of the spouse's death
/.A client becomes angry and threatens another client. What is the nurse's most
therapeutic intervention? - Answer-Encouraging the client to talk about why he or she
became angry and then aggressive
/.A client describes his delusions in minute detail to the nurse. How should the nurse
respond? - Answer-By changing the topic to reality-based events
/.A client has been placed in seclusion as a result of uncontrolled physical aggression
directed toward both the staff and another client. In light of the events set forth in the
documentation, the nurse manager will initially: - Answer-Ask for details regarding how
the staff attempted to manage the client before seclusion was initiated.
/.A client has been prescribed chlorpromazine (Thorazine) for the management of
positive symptoms of schizophrenia. When the client reports difficulty sustaining an
erection, the nurse: - Answer-Consults with his provider regarding alternative
medication therapies
/.A client has been taking escitalopram (Lexapro) for treatment of a major depressive
episode. On the fifth day of therapy the client refuses the medication, stating, "It doesn't
help, so what's the use of taking it?" What is the best response by the nurse? - Answer-
"It can take 1 to 4 weeks to see an improvement."
/.A client has been taking the prescribed dose of clozapine (Clozaril). The nurse should
assess the client for which life-threatening side effect of this drug? - Answer-
Agranulocytosis
/.A client has had repeated hospitalizations for aggressive, violent behavior. While on
the mental health service, the client becomes very angry, starts screaming at the nurse,
and pounds the table. What is the priority nursing assessment at this time? - Answer-
Degree of control over the behavior
/.A client has just been admitted with the diagnosis of borderline personality disorder.
There is a history of suicidal behavior and self-mutilation. The nurse remembers that the
main reason that clients use self-mutilation is to: - Answer-Express anger or frustration.
,/.A client has recently started taking a new neuroleptic drug, and the nurse notes
extrapyramidal effects. Which drug does the nurse anticipate will be prescribed to limit
these side effects? - Answer-Benztropine mesylate (Cogentin)
/.A client is admitted for treatment of obsessive-compulsive disorder that is interfering
with activities of daily living. Which medication should the nurse anticipate the health
care provider will prescribe? - Answer-Clomipramine (Anafranil)
/.A client is admitted to a mental health facility because of maladaptive coping behavior.
How can the nurse best help the client develop healthier coping mechanisms? -
Answer-By setting realistic limits on the client's maladaptive behavior
/.A client is admitted to a psychiatric hospital because of a recurrent mental health
problem. During admission the nurse determines the expected client outcomes. The
nurse concludes that these outcomes are: - Answer-Measurable objectives
/.A client is admitted to the hospital because of incapacitating obsessive-compulsive
behavior. The statement that best describes how clients with obsessive-compulsive
behavior view this disorder is: - Answer-"I know there's no reason to do these things,
but I can't help myself."
/.A client is admitted with a bipolar disorder, depressed episode. The nursing history
indicates a progressive increase in depression over the past month. What should the
nurse expect the client to display? - Answer-Paucity of verbal expression related to
slowed thought processes
/.A client is presented with the treatment option of electroconvulsive therapy (ECT).
After discussion with staff members, the client requests that a family member be called
to help make the decision about this treatment. What ethical principle does the nurse
consider when supporting the client's request? - Answer-Autonomy
/.A client is receiving doxepin (Sinequan). For which most dangerous side effect of
tricyclic antidepressants should a nurse monitor the client? - Answer-Mydriasis
/.A client is to begin lithium carbonate therapy. The nurse should ensure that before the
drug's administration the client has baseline: - Answer-Renal studies
/.A client on the psychiatric service is pacing around the unit at a moderate rate and
looking to either side of the hall. What is the most appropriate intervention by the nurse?
- Answer-Talking with the client to assess the meaning of the behavior
/.A client on the psychiatric unit asks a nurse about psychiatric advance directives
(PADs). What information should form the basis of the nurse's response? - Answer-A
client is allowed to consent to or refuse potential psychiatric treatments if a future
incapacitating mental health crisis occurs.
, /.A client on the psychiatric unit sits alone most of the day. The nurse approaches the
client. As the nurse gets approximately 3 feet away, the client lets out a string of
profanity and shouts, "Leave me alone; I don't want to talk to you!" What is the most
appropriate response by the nurse? - Answer-I'll leave for now, but I'll be back later."
/.A client on the psychiatric unit who has suicidal ideas says to the nurse, "I signed
myself in. I'll sign myself out." What concept provides the basis for the nurse's
response? - Answer-Suicidal clients may not sign out even if they voluntarily admitted
themselves.
/.A client on the psychiatric unit who is receiving high-dosage risperidone (Risperdal) is
exhibiting tremors of the hands. What should be the nurse's first intervention? - Answer-
Contacting the health care provider
/.A client receiving risperidone (Risperdal) is going on an all-day fishing outing with
family members. It is important that the nurse: - Answer-Encourage the client to use
sunscreen.
/.A client sits huddled in a chair and leaves it only to assume the fetal position in a
corner. The nurse, observing this, identifies the behavior as: - Answer-Regressive
/.A client states, "The voices are saying I killed my husband." What is the best response
by the nurse? - Answer-"You're having very frightening thoughts right now."
/.A client tells a mental health nurse about hearing a man speaking from the corner of
the room. The client asks whether the nurse hears him, too. What is the nurse's best
response? - Answer-No, I don't hear him, but it probably upsets you to hear him."
/.A client tells the nurse in the mental health clinic that the practitioner said that the
cornerstone of therapy used in the clinic is cognitive therapy. The client asks what this
therapy entails. What concept should the nurse explain as the basis of cognitive
therapy? - Answer-Negative thoughts can precipitate anxiety."
/.A client who has just experienced her second spontaneous abortion expresses anger
toward the practitioner, the hospital, and the "rotten nursing care." When assessing the
situation, the nurse concludes that the client may be using the coping mechanism of: -
Answer-Displacement
/.A client who has recently become blind as a result of an injury responds to the loss of
autonomy by being sarcastic. How can the nurse best respond to this behavior? -
Answer-By accepting the behavior
/.A client who has schizophrenia is receiving a phenothiazine antipsychotic medication.
Which serious client responses to the medication should the nurse immediately report to
the practitioner? Select all that apply. - Answer-Yellow sclerae
Involuntary tongue movements
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