HESI Psychiatric and Mental Health Nursing

Question 1

HESI Psychiatric and Mental Health Nursing. A client with bipolar disorder tells the nurse about the need to make some deals to improve a retirement savings. Based on this information, which client outcome should the nurse include in the care?

• A Identify the feelings associated with the behavior.
• B Describe feelings of fear about finances.
• C Delay business decisions until mania subsides.
• D Seek legal counsel when making business decisions.

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Question 2

Click to highlight the aspects of the history and physical that represent risk factors for intimate partner violence.

• “She has had minor injuries in the past from falling.”
• “The client is married and is pregnant with her first child.”

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Question 3

The nurse reads the history and physical and enters the room to perform the intimate partner violence screening. Which action(s) can the nurse take to increase the likelihood that the client will disclose abuse if it is happening? Select all that apply.

• A Probe the client if she does not speak up immediately
• B Conduct the interview in private
• C Ask the permission of the husband to perform an exam
• D Use an evidence-based screening tool
• E Convince the client that she is a bad mother if she does not tell
• F Start with less personal questions first to build rapport

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Question 4

The nurse is evaluating the client’s statements. Complete the following sentence by choosing from the lists of options. Considering the cycle of violence, at the time of the visit, the couple is in the Honeymoon phase, which is characterized by Loving behavior.

• Answer 1: Honeymoon
• Answer 2: Loving behavior

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Question 5

The nurse goes on to assess the client’s risk for lethality. Which 2 factors increase the potential for lethal intimate partner violence?

• A Alcohol and drug use
• B A gun in the home
• C Previous marriage
• D Unemployment
• E A history of infidelity
• F Presence of close family members

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Question 6

The nurse works with the client to create a safety plan. Mark whether the statements indicate understanding or no understanding about safety plans. Each row must have one option selected.

• “I will put extra money in our savings account.” — No understanding
• “I should think of safe places to go in case something happens.” — Understanding
• “I should avoid calling the police unless I am ready to leave the relationship.” — No understanding
• “I should only make a safety plan if I decide to stay with my husband.” — No understanding
• “I should let a neighbor know that they should call the police if they hear violence.” — Understanding

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Question 7

Following the visit, which action(s) should the nurse take? Select all that apply. HESI Psychiatric and Mental Health Nursing

• A Document verbatim statements about the abuse
• B Provide referrals from the healthcare provider for mental health services
• C Follow up with the client in a few weeks
• D Call the police as a mandatory reporter
• E Mail education items to the home for batterer treatment options

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Question 8

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

• A A middle-aged man who is troubled with shortness of breath and is diaphoretic.
• B An adolescent who becomes extremely anxious about going outside.
• C A young woman who suddenly goes blind with no indication of organic pathology.
• D An older adult who continuously troubled by a headache and back pain.

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Question 9

An adolescent client is admitted to the postoperative unit following open reduction of a fractured femur which occurred when the client fell down the stairs at a party. The nurse notices needle marks on the client’s arms. Which assessment findings should the nurse document related to suspected narcotic withdrawal?

• A Vomiting, seizures, and loss of consciousness.
• B Agitation, sweating, and abdominal cramps.
• C Hypotension, shallow respirations, and dilated pupils.
• D Depression, fatigue, and dizziness.

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Question 10

A client who is admitted with a closed head injury after a fall has a blood alcohol level (BAL) of 280 mg/dL (60.8 mmol/L) and is difficult to arouse. Which intervention during the first 6 hours following admission should the nurse identify as the priority?

• A Give lorazepam PRN for signs of withdrawal.
• B Provide thiamine and folate supplements as prescribed.
• C Administer disulfiram immediately.
• D Place in a side-lying position with head of bed elevated.

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Question 11

The nurse accepts a client who is being transferred to the mental health unit and understands that the client is distractible and is exhibiting a decreased ability to concentrate. The nurse has only 15 minutes to talk with the client. To develop a treatment plan for this client, which assessment is most important for the nurse to obtain?

• A Motivation for treatment.
• B History of substance use.
• C Mental status examination.
• D Medication compliance.

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Question 12

Click to highlight the aspects of the assessment that require urgent attention.

• “She explains that she keeps having horrible thoughts and memories about the house collapsing”
• “and that it is keeping her from falling asleep.”
• “Now I can’t seem to get out of this funk I am in.”

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Question 13

After listening to the client’s symptoms, the nurse realizes that she likely has __________ related to __________.

Options for 1:

• phobia
• separation anxiety
• hallucinations
• acute stress disorder

Options for 2:

• overstimulation
• undiagnosed mental health disorder
• traumatic stress exposure
• side effects of medication

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Question 14

Click to specify which client statement or behaviors is most likely associated with each of the listed defense mechanisms. Some statements or behaviors may be consistent with more than one mechanism. Each column must have at least one response selected. HESI Psychiatric and Mental Health Nursing

Fantasy:

• The client discusses moving to Hawaii instead of returning to rebuild her house.
• The client is frightened that the hospital will burn down.
• The client says that she sometimes forgets why she is in the hospital.
• The client seems unemotional when talking about needing to rebuild her house.

Isolation:

• The client discusses moving to Hawaii instead of returning to rebuild her house.
• The client is frightened that the hospital will burn down.
• The client says that she sometimes forgets why she is in the hospital.
• The client seems unemotional when talking about needing to rebuild her house.

Suppression:

• The client discusses moving to Hawaii instead of returning to rebuild her house. HESI Psychiatric and Mental Health Nursing
• The client is frightened that the hospital will burn down.
• The client says that she sometimes forgets why she is in the hospital.
• The client seems unemotional when talking about needing to rebuild her house.

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Question 15

Which nursing intervention(s) is/are appropriate for the client starting clonazepam? Select all that apply.

• A Assess mental status regularly
• B Monitor calcium levels
• C Screen for orthostatic hypotension
• D Provide oral care at least twice a day
• E Assist the client to the bathroom
• F Have an opioid agonist at the bedside

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Question 16

Which other treatment(s) might be helpful for this client? Select all that apply.

• A Administration of lithium
• B Phototherapy
• C Animal therapy
• D Electroconvulsive therapy
• E Cognitive behavioral therapy
• F Consciousness raising

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Question 17

Which client statement(s) require(s) follow up teaching by the nurse? Select all that apply.

• A “I will probably need to be on medication for the rest of my life.”
• B “Many people have the same response to a stressful situation as I am having right now.”
• C “This diagnosis means that I am crazy.”
• D “I am at high risk for post traumatic stress disorder because I have acute stress disorder.”
• E “I can learn to manage my thoughts better through therapy.”
• F “I can use holistic approaches like meditation to help my symptoms.”

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Question 18

The nurse is assessing a client whose spouse died of a stroke two weeks ago and who reports having numbness and tingling on the right side of the body. The nurse should consider the client’s symptoms may likely be due to which condition?

• A Reexperience.
• B Somatization.
• C Preoccupation.
• D Disorganization.

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Question 19

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

• A Talks to voices only the client can hear.
• B Tries to run the unit, telling everyone what to do and when to do it.
• C Is openly hostile to others for no apparent reason.
• D Repeatedly tries to commit suicide.

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Question 20

The mother of an infant with profound mental and physical disabilities tells the nurse how depressed she is because she realizes that her child will never achieve normal growth and development milestones. How should the nurse respond to this mother? HESI Psychiatric and Mental Health Nursing

• A Determine if the mother has other children who do not have developmental disabilities.
• B Reassure the mother that her child will achieve some growth and development milestones.
• C Encourage the mother to write thoughts and feelings in a journal.
• D Ask the mother if she has ever thought about harming herself or her child.

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Question 21

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 Progressively expose the client to larger crowds.
• B Encourage substitution of positive thoughts for negative ones.
• C Establish trust by providing a calm, safe environment.
• D Encourage deep breathing when anxiety escalates in a crowd.

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Question 22

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

Potential Conditions:

• Suicidal Ideation
• Acute Stress Disorder
• Tuberculosis
• Serotonin Syndrome

Actions to Take (Select Two):

• Place on contact isolation
• Place on suicide watch
• Apply wrist restraints
• Discontinue antidepressant
• Apply cooling blanket

Parameters to Monitor (Select Two):

• Sputum changes
• Affect
• Isolation precautions
• Temperature
• Hydration

Question 23

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 important for the nurse to establish with this client?

• A Attend at least 2 group sessions daily on the unit.
• B Verbally express anger towards family.
• C Identify three effective ways to cope with feelings.
• D Interact positively with the staff on the unit. HESI Psychiatric and Mental Health Nursing

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Question 24

A client who was admitted 3 days ago for a bowel obstruction has a liter of lactated Ringer’s with potassium chloride (KCl) 20 mEq infusing. The client has been receiving selegiline for depression. When the client reports experiencing a severe headache, the nurse obtains a blood pressure of 200/110 mm Hg. Which action(s) should the nurse take? Select all that apply.

• A Monitor blood pressure and pulse every 15 minutes.
• B Measure hourly urinary output.
• C Notify healthcare provider of client’s findings.
• D Withhold the next dose of selegiline.
• E Discontinue the IV infusion.

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Question 25

The nurse is planning the care for a client who is hospitalized with a bipolar disorder. The client wanders the hallways, talks excessively, and makes sexual comments about the staff. Which intervention(s) should the nurse include in the plan of care? Select all that apply. HESI Psychiatric and Mental Health Nursing

• A Assign the client to a single room.
• B Invite for a walk when client’s energy is high.
• C Engage the client in competitive activities.
• D Provide television programs with suspense to keep attention engaged.
• E Give concise and firm directions for hygiene and dressing.

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Question 26

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

• A Postpone the client interview until the next day.
• B Attempt to ask the client simple questions.
• C Document the client’s paranoid behavior.
• D Ask another nurse to talk with the client.

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Question 27

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 School grades and extracurricular activities.
• B Frequency of binging and purging behaviors.
• C Perceptions of family and social relationships.
• D National percentile of weight and height.

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Question 28

Which short-term outcome should the nurse include in the initial treatment plan for a client with dementia?

• A Performs activities of daily living for 3 sequential days.
• B Verbalizes no hallucinations and delusions for 48 hours.
• C Expresses no paranoid ideation for at least 1 week.
• D Remembers family member’s names at their next visit.

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Question 29

The nurse is providing teaching to a client and family about schizophrenia before discharge from an inpatient facility. The nurse should instruct the family to notify the healthcare provider when which behavior is observed?

• A Decreased attention to detail.
• B Social withdrawal. HESI Psychiatric and Mental Health Nursing
• C Changes in appetite.
• D Fear of large dogs.

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Question 30

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

• A Benzodiazepine.
• B Methamphetamine.
• C Marijuana.
• D Alcohol.

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Question 31

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

• A The effects of amitriptyline can promote and potentiate the risk of lithium toxicity.
• B Creatinine can measure how the body is metabolizing the lithium in the liver.
• C The combination of lithium and amitriptyline may need to be changed if creatinine is high.
• D Lithium is excreted by the kidneys and creatinine is related to kidney functioning.

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Question 32

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

• Potential Condition: Delirium
• Actions to Take: Initiate fall precautions
• Actions to Take: Reorient the client to her surroundings
• Parameters to Monitor: Mental status
• Parameters to Monitor: Environmental stimuli around the client

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Question 33

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 administered if the client begins to exhibit signs and symptoms of delirium tremens (DTs)?

• A Chlorpromazine 50 mg IM.
• B Lorazepam 2 mg IM.
• C Hydromorphone 2 mg IM.
• D Prochlorperazine 5 mg IM.

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Question 34

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

• A Familial history of mental illness.
• B Current weight.
• C Medication history.
• D Any history of heart disease.

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Question 35

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 Stimulation and dilated pupils. HESI Psychiatric and Mental Health Nursing
• B Bradycardia and bradypnea.
• C Hallucinations and delusions.
• D Lethargy and depression.

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Question 36

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 client’s plan of care?

• A Lead the client by the arm to the seclusion room.
• B Ensure the client’s environment is safe.
• C Confront the client’s delusion as not consistent with reality.
• D Schedule activity therapy twice weekly.

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Question 37

When assessing a female client who has been taking an antipsychotic medication 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 healthcare provider. Which additional action should the nurse take?

• A Prepare to initiate seizure precautions for the client’s safety.
• B Assist the client in recognizing her manifestations of anxiety. HESI Psychiatric and Mental Health Nursing
• C Advise the client that she has developed tolerance to the medication.
• D Document the finding on the Abnormal Involuntary Movement Scale.

Question 47

A nurse who is co-leading 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 Ask the client to describe and identify the source of the feelings.
• D Escort the client from the group to reduce stimuli. HESI Psychiatric and Mental Health Nursing

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Question 48

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 Remain alcohol free for 12 hours prior to the first dose.
• C Completely abstain from heroin or cocaine use.
• D Admit to others that he is a substance abuser.

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Question 49

Naloxone is administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate. Within 15 minutes, the client is alert and 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 client’s reason for attempting suicide.
• C Obtain the client’s serum hydrocodone/acetaminophen level.
• D Observe the client for further narcotic effects.

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Question 50

A client is receiving benztropine mesylate for drug-induced extrapyramidal syndrome (EPS). Which finding indicates that the nurse should further evaluate the client?

• A Presence of a dry mouth.
• B Decreased bowel movements. HESI Psychiatric and Mental Health Nursing
• C Decreasing hand tremors.
• D Increased mouth movements.

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Question 51

A client is admitted to the psychiatric inpatient unit 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, and suffering from a breakup of a current relationship last week. Which is the most likely source of this client’s current feelings of depression?

• A Poor self esteem.
• B A sense of loss.
• C Feelings of frustration.
• D A lack of intimate relationships.

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Question 52

(Case Study: 32-year-old female with alcohol history) Complete the following sentence by dragging the correct risk and nursing actions.

The client is at risk for Alcohol withdrawal and the nurse should plan to Administer lorazepam and Implement seizure precautions.

• Risk: Alcohol withdrawal
• Action 1: Administer lorazepam
• Action 2: Implement seizure precautions

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Question 53

(Case Study continued: Client with tremors, Pulse 110, BP 150/92) Which intervention is the priority for the nurse to implement?

• A Monitor the client’s vital signs every 15 minutes.
• B Administer the PRN dose of lorazepam.
• C Allow the client’s spouse to visit at the bedside.
• D Encourage the client to increase oral fluid intake.

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Question 54

(Case Study: 78-year-old female with history of wandering, aphasia, and agitation) Review the client data and complete the sentence.

The client is most likely experiencing a Neurocognitive disorder and the nurse should Speak to the client in a calm, low voice and Provide a quiet, low-stimulus environment.

• Condition: Neurocognitive disorder
• Action 1: Speak to the client in a calm, low voice
• Action 2: Provide a quiet, low-stimulus environment HESI Psychiatric and Mental Health Nursing

Question 52

The nurse reviews the client’s data. Drag one client finding and one rationale to complete the sentence.

The client is at risk for developing hypoglycemia due to a(n) inability to eat.

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Question 53

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

• A Resolve the feelings with the client after discharge.
• B Share similar experiences the nurse has had in the past.
• C Terminate the session before the feelings escalate.
• D Identify the client’s transference of feelings of annoyance.

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Question 54

A client with an obsessive compulsive disorder (OCD) reports difficulty focusing on tasks and maintaining relationships. The client expresses a desire to change this behavior and improve on decision-making. Which action should the nurse implement?

• A Suggest strategies to reduce daily stress.
• B Request a prescription for lithium carbonate.
• C Provide recovery-oriented client care.
• D Give information about in-patient treatment.

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Question 55

A preschool-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 to the nurse that the hair loss is not disease related?

• A Ecchymotic blood accumulations.
• B Erythema of the localized lesions.
• C Episodic reports of pruritus.
• D Evidence of patches of lost hair.

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Question 56

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

• A “Have you experienced recent stresses?”
• B “Do you often feel sad?”
• C “Have you experienced sleep changes?”
• D “What foods do you like to eat?”

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Question 57

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 adolescent who is depressed over not being accepted by peers.
• B An older adult resident of a long term care facility who sometimes takes other residents’ belongings.
• C A hyperactive 4-year-old who has recently been tested for autism.
• D An adult with schizophrenia who often refuses to take prescribed antipsychotic medications.

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Question 58

A female client presents in the emergency department (ED) and states, “I was raped tonight.” Which intervention is most important for the nurse to implement?

• A Obtain a history of sexually transmitted diseases.
• B Instruct the client to remove all clothing carefully.
• C Assess client’s sexual activity for the past 30 days.
• D Ask the client if she can identify the attacker.

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Question 59

An adult female client with bipolar disorder is seen in the outpatient psychiatric clinic and tells the nurse that she is thinking of harming her sister. Which action is most important for the nurse to take?

• A Report the threat to the healthcare team.
• B Notify the healthcare provider of the threat.
• C Inform the sister of the client’s threat.
• D Document the threat in the medical record.

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Question 60

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? HESI Psychiatric and Mental Health Nursing

• A Isolate the client from other clients.
• B Avoid recognizing the behavior.
• C Administer a PRN sedative.
• D Escort the client to a private area.