WGU Mental Health D449 Hesi Latest updated version with expert curated questions and answers

1. The charge nurse of the psych unit observes clients in the day area. Which client is exhibiting symptoms of a conversion disorder?

a. a young woman who suddenly goes blind with no indication of organic pathology

b. An adolescent who becomes extremely anxious about going outside

c. A middle aged man who is troubled with shortness of breath & its diaphoretic

d. An older adult who continuously troubled by a headache & back pain

a. a young woman who suddenly goes blind with no indication of organic pathology

11. An older male resident of a long term facility who is chronically depressed has become more reclusive & refuses to leave his room today. His family moved away from the local are, and they are unable to visit as much as they did in the past. Which comment by the nurse is likely to be most helpful to this client?

a. "Why do you want to stay in your room today?"

b. "May I sit with you for a while?"

c. "Come into the recreation area. We have your favorite card game & I will play it with you"

d. I know you are sad about not seeing your family as often, but they are visiting as much as they can

Answer C - "Come into the recreation area. We have your favorite card game & I will play it with you"

8. A nurse who is colliding group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?

a. Provide education about ways to cope with anxiety

b. Assist the client with relaxation techniques in the group

c. Escort the client from the group to reduce stimuli

d. Ask the client to describe & identify the source of the feelings

Answer B- Assist the client with relaxation techniques in the group

9. The nurse plans to use role playing as a therapeutic measure. Which individual is most likely to benefit from this type of therapeutic intervention?

a. An older adult resident of a long term care facility who sometimes takes other residents belongings

b. An adult with schizophrenia who often refuses to take px antipsychotics mxc

c. A hyperactive 4 yr old who has recently been tested for autism

d. an adolescent who is depressed over not being able to accepted by peers.

Answer D - an adolescent who is depressed over not being able to accepted by peers.

10. During a one-to-one session, the nurse begin to become angry with the client. Which action should the nurse take?

a. Identify the clients transference of feelings of annoyance

b. Resolve the feelings with the client after discharge

c. Share similar experiences the nurse has had in the past

d. Terminate the session before the feelings escalate

Answer D- Terminate the session before the feelings escalate

18. Following involvement in a motor vehicle collision a middle aged adult client is admitted to the hospital with multiple facial fractures. The clients blood alcohol level is high on admission. Which PRN rx should be administered if the client begins exhibit signs & symptoms of delirium tremens.

a. Hydromorphone 2 mg IM

b. Chlorpromazine 50 mg IM

c. Prochlorperazine 5mg IM

d. Lorazepam 2mg IM

Answer D- Lorazepam 2mg IM

19. A client who has been abused by a spouse multiple times is admitted to the ED. when taking the history, which information is most important for the nurse to obtain?

a. Discuss injuries that occurred from the previous abuse

b. Ask if the spouse drinks alcohol or does drugs before abuse occurs

c. Find out the circumstances that prompted this abusive episode

d. determine if the client has a plan to leave if their life is in danger.

Answer D - Determine if the client has a plan to leave if their life is in danger.

20. The mental health unit nurse completes the admission assessment for a depressed adolescent client with suicidal ideation. The client reports becoming angry wIth a sibling, so the client took a handful of pills. Which goal is most for the nurse to establish with this client?

a. Verbally express anger towards family

b. Attend at least 2 group sessions daily on the unit

c. Interact positively with the staff on the unit

d. identify 3 effective ways to cope feelings

Answer d. identify 3 effective ways to cope feelings

21. . An adolescent client is admitted to the postop unit following open reduction of a fractured femur when the client fell downstairs at a party. The nurse notices needle marks on the clients arms. Which assessment findings should the nurse document r/t to suspected narcotic withdrawal?

a. Depression, fatigue, & dizziness

b. Vomiting, seizure, & loss of consciousness

c. Hypotension, shallow respirations, & dilated pupils

d. agitation, sweating, & abdominal cramps

Answer D - agitation, sweating, & abdominal cramps

23. The nurse is performing intake interviews at a psych clinic. A female client with a known history of drug abuse reports that she had a heart attack 4 yrs ago. Use of which substance places at highest risk for myocardial infarction?

a. methamphetamine

b. Marijuana

c. Alcohol

d. benzodiazepine

Answer A- methamphetamine

24. On admission to the mental health unit, a client diagnosed with schizophrenia tells the nurse, I am the son of GOD. Based on this statement, which intervention should the nurse include in this clients plan of care?

a. Confront the clients delusion as not consistent with reality

b. ensure the clients environment is safe

c. Schedule activity therapy twice weekly

d. Lead the client by the arm to the seclusion room

Answer b. ensure the clients environment is safe

25. The nurse is completing the admission assessment of an adolescent client who is underweight & admitted to a psychiatric unit with a diagnosis of depression. Which findings require notification to the HCP.

a. BP of 110/70 mmHg

b. potassium of 2.0 mEq/L

c. BMI of 21 kg

d. WBC of 10,000/mm3

Answer - b. potassium of 2.0 mEq/L

26. A client who is admitted with a closed head injury after a fall has blood alcohol level (BAL) of 280 mg/dl., & is difficult to arouse. Which intervention during the first 6 hrs following admission should the nurse identify as the priority?

a. Give lorazepam PRN for signs of withdrawal

b. Place in a side-lying position with HOB elevated.

c. Provide thiamine & folate supplements as prescribed

d. Administer disulfiram immediately

Answer b. Place in a side-lying position with HOB elevated.

27. An adolescent who was arrested a month ago for gang-r/t activities has a court order to attend weekly group therapy sessions at the mental health clinic. Today the adolescent mother calls the clinic nurse to report that her child became angry last night & put a list through a window. Which intervention is most important for the nurse to implement?

a. advise the mother to call the police if violent behavior occurs again

b. Reinforce the need for the adolescent to attend group therapy session

c. Tell the mother to describe her feelings of helplessness to her child

d. Refer the mother for psych evaluation for anxiety & depression.

Answer - a. advise the mother to call the police if violent behavior occurs again

28. The nurse is assessing a client with paranoia. Which behavior can this client be expected to exhibit?

a. is openly hostile to others for no apparent reason

b. Repeatedly tries to commit suicide

c. Tries to run the unit, telling everyone what to do & when to do it

d. Talk to voices only the client can hear

Answer a. is openly hostile to others for no apparent reason

29. An adult female client with bipolar disorder is seen in the outpatient psych clinic & tells the sister. Which action is the most important for the nurse to take?

a. Report the threat to the healthcare team

b. Inform the sister of the clients threat

c. Document the threat in the medical record

d. notify the HCP of the threat

Answer d. notify the HCP of the threat

30. A female client presents in the ED & states, I was raped tonight. Which intervention is most important for the nurse to implement?

a. Obtain a history of STDs

b. Assess clients sexual activity for the past 30 days

c. instruct the client to remove all clothing carefully

d. Ask the client if she can identify the attacker

Answer c. instruct the client to remove all clothing carefully

31. A male client arrives at the mental health clinic & asks the nurse for more lithium & the antidepressant amitriptyline that he uses to help him sleep. After reviewing the assessment findings with the Hcp a serum creatinine is obtained. Which information supports the reason for this lab test?

a. lithium is excreted by the kidneys & creatinine is r/t to kidney functioning

b. Creatinine can measure how the body is metabolizing the lithium in the liver

c. The effects of amitriptyline can promote & potentiate the risk of lithium toxicity

d. The combination of lithium & amitriptyline may need to be changed if creatine is high

Answer- a. lithium is excreted by the kidneys & creatinine is r/t to kidney functioning

33. The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help bc his wife said he had a drinking problem. Which information should the nurse explore in depth with the client based on this screening tool?

a. Cancer screening results, anger gastritis, daily alcohol intake

b. Efforts to cut down, annoyance with questions, guilt, drinking as an eye opener

c. Consumption, liver enzyme, GI complaints, & bleeding

d. Minimizes drinking, frequently misses family events, guilt about drinking, amount of daily intake

Answer b. Efforts to cut down, annoyance with questions, guilt, drinking as an eye opener

34. The nurse is planning care for a client who is hospitalized with bipolar disorder. The client wanders the hallways, talks excessively. Which intervention should the nurse include in the plan of care? sATA

a. give concise & firm directions for hygiene & dressing

b. Engage the client in competitive activities

c. invite for a walk when clients energy is high

d. assigns the client to a single room

e. Provide television programs with suspense to keep attention engaged

Answer: A/C/D

35. A high school girl reveals to the school nurse that she has been engaging in self induced vomiting as a weight control measure. Which initial assessment should the nurse focus on with this adolescent?

a. Perceptions of family & social relationships

b. School grades & extracurricular activities

c. National percentile of weight & height

d. frequency of binging & purging behaviors

Answer d. frequency of binging & purging behaviors

36. The nurse accepts a client who is being transferred to the mental health unit & understands that the client is distractible & is exhibiting a decreased ability to concentrate. The nurse has only 15 mins to talk to the client. To develop a TX plan for this client, which assessment is most important for nurse to take?

a. History of substance use

b. Medication compliance

c. mental status examination

d. motivation for treatment

Answer c. mental status examination

37. The nurse is teaching a client about the initiation of a prescribed abstinence therapy using disulfiram. Which information should the client provide to acknowledge understanding?

a. Attend monthly meetings of alcoholics anonymous

b. Completely abstain from heroin or cocaine use

c. remain alcohol free for 12 hrs prior to the first dose

d. Admit to others that he isa substance abuser

Answer C- remain alcohol free for 12 hrs prior to the first dose

38. A client at the mental health center reports difficulty concentrating at work feeling very tired during the day, & seeing 4-5 hrs at night. To further assess depression, which question is most important for the nurse to ask?

a. "What foods do you like to eat?"

b. "Have you experienced recent stresses?"

c. "Have you experienced sleep changes?"

d. "do you often feel sad?"

Answer d. "do you often feel sad?"

39. Which short term outcome should the nurse include in the initial Tx plan for a client with dementia?

a. Remembers family members names at their next visit

b. Expredsses no paranoid ideation for at least 1 week

c. Performs activities of daily living for 3 sequential days

d. Verbalizes no hallucination & delusions for 48 hrs

c. Performs activities of daily living for 3 sequential days

40. A client who was admitted 3 days ago for bowel obstruction has a liter of lactated ringers with potassium chloride 20 mEq infusing. The client has been receiving selegiline for depression. When the client reports experiencing a severe headache the nurse obtains a BP of 200/110 mmHg. Which actions should the nurse take? SATA

a. Discontinue the iv infusion

b. notify HCP of clients findings

c. monitor BP & pulse every 15 mins

d. Measure hourly urinary output

e. Withhold the next dose of selegiline

Answer: B/C/E

41. The nurse is providing teaching to a client & family about schizophrenia before discharge from an inpatient clinic. The nurse should instruct the family to notify HCP when which behavior is observed?

a. Decreased attention to detail

b. social withdrawal

c. Changes in appetite

d. Fear of large dogs

b. social withdrawal

43. A pre-school aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates that the hair loss is not disease r/t?

a. ecchymotic blood accumulation

b. Erythema of the localized lesion

c. Episodic reports of pruritus

d. Evidence of patches of lost hair

a. ecchymotic blood accumulation

44. 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 the clients plan of care?

a. Encourage deep breathing when anxiety escalates in a crowd

b. Encourage substitution of positive thoughts for negative ones

c. Progressively expose the client to larger crowds

d. Establish trust by providing a calm, safe environment

d. Establish trust by providing a calm, safe environment

45. A client is admitted to the mental health unit & sits in the corner of the day room. When the nurse begins the admission interview, the client is guarded, & resists talking. Which action should the nurse implement?

a. Postpone the client interview until the next day

b. Document the clients paranoid behavior

c. Ask another nurse to talk with the client

d. Attempt to ask the client simple questions

d. Attempt to ask the client simple questions

46. The mother of an infant with profound mental & physical disabilities tells the nurse how depressed she is because she realizes that her child will never achieve normal growth & developmental milestones. How should nurse respond to this mother?

a. Reassure the mother that her child will achieve some growth & development milestones

b. Ask the mother if she has ever thought about harming herself or her child

c. Determine if the mother has other children wo do not have developmental disabilities

d. Encourage the mother to write her thoughts & feelings in a journal

47. A young female client is admitted in the ED bc she was raped that evening by her date. Which computer documentation should the nurse enter in the EMR at the clients chief concern?

a. Client reported that she had sexual relations against her will

b. Cllient states, "my date raped me last night

c. Client has been sexually assaulted

d. Client claims that she was forced to participate in sexual intercourse

b. Cllient states, "my date raped me last night

48. A client is receiving benztropine mesylate for drug induced EPS. Which finding indicates that the nurse should further evaluate the client?

a. Increased mouth mvmnts

b. Presence of a dry mouth

c. Decreasing hand tremors

d. Decreased bowel mvmnts

a. Increased mouth mvmnts

49. A client with ocd reports difficulty focusing on tasks & maintaining relationships. The client expresses a desire to change this behavior & improve on decision making. Which actions should the nurse implement?

a. Request a rx for lithium carbonate

b. Suggest strategies to reduce daily stress

c. Provide recovery oriented client care

d. GIve information about in pt treatment

50. A client is admitted to the psych inpatient with a bandaged flesh wound after attempting self injury by shooting. The client reports going through a divorce one year ago, job loss four months ago, & suffering from a breakup of a current relationship last week. Which is most likely the source of this clients current feelings of depression?

a. Poor self esteem

b. A lack of intimate relationship

c. sense of loss

d. Feelings of frustration

c. sense of loss

51. A client with bipolar disorder tells the nurse about the need to make some deals to improve retirement savings. Based on the information, which client outcome should the nurse include in the care?

a. delay business decisions until mania subsides

b. Identify the feelings associated with the behavior

c. Seek legal counsel when making business decisions

d. Describe feelings of fear about finances

a. delay business decisions until mania subsides

53. A client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. Which intervention is best for the nurse to implement?

a. Avoid recognizing the behavior

b. escort the client to a private area

c. Isolate the client from other clients

d. Administer a PRN sedative

b. escort the client to a private area

54. A client with major depressive disorder is admitted to the inpatient psych unit. Which intervention should the nurse use to demonstrate support of the client?

a. Recommend journaling & time taken in self reflection

b. Incorporate animated communication techniques

c. Assist the client to identify symptoms of depression

d. schedule regular periods of time for interaction with client

d. schedule regular periods of time for interaction with client

55. Prior to initiating a treatment regimen with the antidepressant sertraline, it is most important for the nurse to obtain which information?

a. Current weight

b. Medication history

c. any history of heart disease

d. Familial history of mental illness

56. When assessing a female client who has been taking antipsychoticsMX for the past year. The nurse observes that the client demonstrates involuntary foot tapping while both feet are flat on the floor. The nurse plans to report the observation to the HCP. Which additional action should the nurse take?

a. document the finding on the abnormal involuntary movement scale

b. Assist the client in recognizing her manifestations of anxiety

c. Prepare to initiate seizure precautions for the clients safety

d. Advise the client that she has developed tolerance to the medication

a. document the finding on the abnormal involuntary movement scale

57. The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?

a. Bradycaria & bradypnea

b. Hallucination & delusions

c. Lethargy & depression

d. stimulation & dilated pupils

d. stimulation & dilated pupils

58. The nurse is performing the admission assessment for a client with schizophrenia in an acute care inpatient facility. The nurse should identify which observed behavior is characteristic of schizophrenia?

a. responds with illogical answers to questions

b. Describes times of depression followed by feelings of euphoria

c. Admits to frequently thinking about committing suicide

d. Exhibits compulsive ritualistic behaviors

a. responds with illogical answers to questions

* 59. The nurse is assessing a client whose spouse died of a stroke 2 weeks ago & who reports having numbness and findings on the right side of the body. The nurse should consider if the client's symptoms may likely be due to which condition?

a. Reexperience

b. Somatization

c. Preoccupation

d. Disorganization

b. Somatization

60. Naloxone (Narcan) is administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate. Within 15 mins the client is alert & oriented. While planning nursing care, which intervention has the highest priority at this time?

a. Encourage the client to increase fluid intake

b. Determine the clients reason for attempting suicide

c. observe the client for further narcotic effects

d. Obtain the client's serum hydrocodone/acetaminophen level

c. observe the client for further narcotic effects