MENTAL HEALTH HESI RN TEST BANK NEWEST 2024 ACTUAL EXAM COMPLE QUESTIONS AND CORRECT DETAILED ANSWERS (VERIFIED ANSWERS)

A client with bulimia and depression who is taking phenelzine (Nardil) 90 mg daily is admitted to an acute care hospital for uncontrolled hypertension. What dietary choices should the RN instruct the client to avoid?

A. Pan-seared catfish

B. Deep fried shrimp

C. Pepperoni pizza

D. Beef trips with gravy

c

A mental health worker is caring for a client with escalating aggressive behavior. Which action by the metal health worker warrants immediate intervention by the RN?

A. is attempting to physically restrain the patient

B. Remains at a distance of 4 feet from the client

C. Tells the client to go to quiet area of the unit

D. Is using a loud voice to talk to the the client

A

A client who is recently experienced a death of a significant other arrives at the mental health center. The client reports loss of interest in usual activities, expresses a wish to be with the deceased significant other, had been eating very little, and has not slept in several days. Which client statement is most important for the RN to explore at this time?

A. no sleeping for several days

B. wishing to be with spouse

C. lack of interest in usual activities

D. eating very little

a

A middle aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and motivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?

A. Provide education on methods to enhance sleep.

B. Teach the client to develop a plan for daily structured activities.

C. Suggest that the client develop a list of pleasurable activities.

D. Encourage the client to exercise.

b

When developing a plan of care for a client admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing problem has the highest priority?

A. impaired comfort

b. risk for injury

c ineffective breathing pattern

d ineffective copping

c

A female client on a psychiatric unit is sweating profusely while she vigorously does push ups and then runs the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbance, the client shouts "I am the boss here. I do what i want" Which nursing problem best supports these observations?

a. Deficient diversional activity related to excessive energy

b. risk for other related violence related to disruptive behavior

c. risk for activity intolerance related to disruptive behavior.

d. disturbance personal identity related to grandiosity

b

A RN is preparing the physical environment to interview a new client for admission to the unite. Which environmental setting facilitates the best outcome of the interview?

a. dim the lights in the room to help the patient feel calm

b. sit within 2 feet of the client to enhance level of safety & security

c. reduce the noise level in the room by turning off the television and radio

d. position table between the client and the RN for extra personal space

c

An older homeless client visits the psychiatric clinic to obtain a prescription renewal for alprazolam (Xanax). During the health assessment, the client complains of chest pain. Which action should the RN take first?

A. Refer the client to the cardiology unit.

B. Obtain the client Blood pressure.

C. Assess the client for substance abuse.

D. Determine if Xanax was taken recently.

d

The mother of an 8-month-old infant with profound mental and physical disabilities tells he RN how depressed she is because she realized that her child will never achieve normal growth and development milestones. How should the RN respond to the mother?

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

B. Reassure the mother that her child will achieve some growth and development milestones.

C. Determine if the mother has other children who do not have developmental disabilities.

D. Encourage the mother to write thoughts and feelings in journal.

a

several client with chronic mental illness and multiple substance abuse histories live in a group residential home and attend daycare mental health facility where group and individual therapies are provided. The RN find the common bathroom at the facility with sputum on the walls, urine in the sink and on the floors, and the toilet stopped ip with tissues, paper towels, and feces. What is the priority issues that the RN should address?

a. Medication non-compliance

b. Number of bathroom facilities

c. infection control

d. acting out behavior

c

A client with schizophrenia is admitted to the psychiatric unit for aggressive behavior, auditory hallucinations, and potential for safe harm. The client has not been taking medications as prescribed and insists the food has been poisoned and refuses to eat. What intervention should the RN implement?

a. assure the client that all food served in the hospital is safe to eat

b. tell the client that irrational thinking is a symptom of schizophrenia

c. obtain an order for a tube feeding for the client

d. provide the client with food in unopened containers

d

The RN is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan. Select all that apply

a. purchase a gun to use for protection

b. establish a code with family and friends to signify violence

c. take a self defense course that retaliates the abuser with injury

d. have a bag ready that has extra clothes for self and children

e. plan an escape route to use if the abuser blocks the main exit

b d e

The RN is admitting a male client who is taking lithium carbonate (Eskalith) twice a day. Which information should the RN report to the HCP immediately?

a. short term memory loss

b. Five pound weight gain

c. decreased affect

d. nausea and vomiting

d

A male client who is admitted with delirium tremens is dehydrated and experiencing auditory hallucinations. He has a bruised swollen tongue and is confused. In developing a plan of care, which action should the RN include to ensure the client is physiologically stable?

a. encourage oral fluids

b. monitor VS

c. keep the room dark

d. apply ice to the tongue

b

A RN is teaching a client about initiation of a prescribed abstinence therapy using Disulfiram (Antabuse). What information should the client acknowledge understanding?

A. Admit to others that he is a substance abuser.

B. Remain alcohol free for 12 hours prior to first dose.

C. Attend monthly meetings of alcoholics anonymous.

D. Completely sustain from heroin or cocaine use.

b

The RN is working with a male client at a community mental health center when the client reports hearing voices that tell him to get a knife from the kitchen and hurt himself. What intervention is most important for the RN to implement?

A. Don't allow the client to go into the kitchen until the hallucination has subsided.

B. Report the behavior to the client's case workers so that the family can be notified.

C. Assign the UAP to remain with the client at all times.

D. Document the behavior in the client's record and notify the HCP.

c

A homeless client who reports feeling sad and depressed tell the mental health nurse that in the past 2 days she has only had 4 hours of sleep. Which action is most important for the RN to implement within the first 24 hours after treatment is initiated?

a. allow the client to rest and sleep

b. ensure the client attend groups addressing coping skills for dealing with depression

c. begin planning for the clients discharge

d. encourage verbalization of feelings

a

Which client statement suggests the RN that the client is using a defense mechanism of projection with anxiety related to admission to a psychiatric unit?

a. at least I hit the wall instead of hitting the psychiatric aide

b. I am here because the police thought I was doing something wrong

c. I want to be here because I know it the best psychiatric facility

d. Don't believe everything my family tells you, I am not crazy

b

A male client is admitted to the psychiatric inpatient unit with a bandaged flesh would after attempting to shoot himself. He was divorced one year ago. Lost his job four months ago, and suffered a breakup of his current relationship last week. What is most likely source of this clients current feeling of depression?

a. feeling of frustration

b. a sense of loss

c. poor self esteem

d a lack of intimate relationships

b

The RN documents the status of a female client who has been hospitalized for several days by court order. The clients states "I don't need to be here" and tells the RN that she believes the tv talks to her. The RN should document these assessments in which section of the mental status exam?

a. insight and judgement

b. mood anf affect

c. remote memory

d. level of concentration

a

The older age client with schizophrenia is found smearing feces in the bathroom walls of the chronic mental health unit where he resides. What action should the RN implement?

a. explain that feces belongs in the toilet

b. show the client how to clean the walls

c. escort the client out of the bathroom

d. assist the client to clean the walls.

c

A male client tells the RN that he does not want to take the atypical antipsychotic drug, olanzapine (Zypexa), because of the side effects he experienced when he took the drug for a year. Which experience is most likely related to taking olanzapine?

a. weight gain of 75 Ibs

b. thought of wanting to hurt himself

c. frequent days with diarrhea

d. altered liver function test

a

A college student who is a victim of a car jacking presents to the community health center and reports increased anxiety. During the interview, what nursing intervention should take the highest priority?

a. identify support systems in the community that may be helpful

b. help the client to feel safe to decrease anxiety

c. ask the client to describe coping strategies that were helpful in the past

d. Encourage the client to verbalize anxiety related to event

b

The RN completes an assessment of a client who is experiencing intimate partner violence (IPV). Which finding of the injuries should the RN include in the documentation?

A. A summary of the client's feelings.

B. Photographs.

C. A general description.

D. A client's significant other's statement.

b

Following involvement in a motor vehicle collision, a middle aged adult client is admitted to the hospital with multiple facial fractures. The client's blood alcohol level is high on admission. Which PRN prescription should be administer if the clients begins to exhibit signs and symptoms of delirium tremens (DT s)?

a. Lorazepam (Ativan) 2mg IM

b. Chlorpromazine (thorazine) 50 mg IM

c. Prochlorperazine (Compazine) 5 mg IM

d. Hydromorphone (Dilaudid) 2 mg IM

a

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

c

The RN 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).

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 RN to ask the client?

a. Have you lost interest in the thing 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

d

A female client requests that her husband be allowed to stay in the room during the admission assessment. When interviewing the client. the RM notes a discrepancy between the clients 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 clients verbal messages

d. integrate the verbal and nonverbal messages and interpret them as one

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 and 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. Splitting

B. Projection

C. Rationalization

D. Denial

b

A mental health worker is caring for a client with escalating aggressive behavior. Which action by the MHW warrant intervention by the RN?

a. is attempting to physically restrain the patient

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

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 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 client

c

A male client with bipolar disorder who began taking lithium carbonate 5 days ago is complaining of excessive thirst and the RN finds him attempting to frink water from the bathroom faucet. Which intervention should the RN implement?

a. report the clients serum lithium level to the HCP

b. Encourage the client to suck on hard candy to relieve the symptoms

c. no action is needed since polydipsia is a common side effect

d. tell the client that drinking from the faucet is not allowed

a

During an annual physical by the occupational RN working in a corporate clinic, a male employee tells the RN that is high stress job is causing trouble is his personal life. He further explains that he often gets so angry while friving to and from work that he has considered "getting even" with other drivers. How should the RN respond?

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 situation

d. it sounds as if there are many situations that make you feel angry

d

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 clients plan of care?

a. establish 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.

b

which nursing actions are likely to help promote the self-esteem of a male client with modern depression? SELECT ALL THAT APPLY

a. ask the client what his long term goals are

b. discuss the challenge 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

d

e

A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of Risperidone (Riserdal). When the client walks to the nurses station in a laterally contracted position, he states that something has made his body contort to a monster. What action should the RN take?

a. medicate the client with the prescribed antipsychotic thioridazine (Mallaril)

b. offer the client a prescribed physical therapy hot pack for muscle spasms

c. direct content to occupational therapy to distract him from somatic complaints

d. Administer the prescribed anticholinergic benzotropin (cogentin) for dystonia

d

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

d