HESI MENTAL HEALTH RN V1 -V3 TEST BANK EXAM QUESTIONS AND
ANSWERS NGN SELF ASSESSMENT DOCUMENT 2024
Pepperoni pizza. - ANSWER--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?
Is attempting the physically restrain the patient. - ANSWER--A mental health worker is caring for a client with escalating aggressive behavior. Which action by the mental health worker warrants immediate intervention by the RN?
Not sleeping for several days. - ANSWER--A client who recently experienced the 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 decreased significant other, has 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?
Teach the client to develop a plan for daily structured activities. - ANSWER--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?
Ineffective breathing pattern. - ANSWER--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?
Risk for other related violence related to disruptive behavior. - ANSWER--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, 1 / 4
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?
Reduce the noise level in the room by turning off the television and radio. - ANSWER--A RN is preparing the physical environment to interview a new client for admission to the mental health unit. Which environmental setting facilitates the best outcome of the interview?
Determine if Xanax was taken recently. - ANSWER--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?
Infection control. - ANSWER--Several clients 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 finds the common bathroom at the facility with sputum on the walls, urine in the sink and on the floors, and the toilet stopped up with tissue, paper towels, and feces. What is the priority issue that the RN should address?
Provide the client with food in unopened containers. - ANSWER--A client with schizophrenia is admitted to the psychiatric care unit for aggressive behavior, auditory hallucinations, and potential for safe harm. The client has not been taking medications as prescribed and insists that the food has been poisoned and refuses to eat. What intervention should the RN implement?
Establish a code with family and friends to signify violence. 2 / 4
Have a bag ready that has extra clothes for self and children.
Plan an escape route to use if the abuser blocks the main exit. - ANSWER--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? (SOA)
Nausea and vomiting. - ANSWER--The RN is admitting a male client who take lithium carbonate (Eskalith) twice a day. Which information should the RN report to the HCP immediately?
Monitor vital signs. - ANSWER--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?
Assign the UAP to remain with the client at all times. - ANSWER--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?
Allow the client to rest and sleep. - ANSWER--A homeless client who reports feeling sad and depressed tells 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?
I am here because the police thought I was doing something wrong. - ANSWER-- Which client statement suggests the RN that the client is using a defense 3 / 4
mechanism of projection to deal with anxiety related to admission to a psychiatric unit?
A sense of loss - ANSWER--A male client is admitted to the psychiatric inpatient unit with a bandaged flesh wound after attempting to shoot himself. He was divorced one year ago. Lost his job four months ago, and suffered a breakup of is current relationship last week. What is most likely source of this client's current feelings of depression?
Insight and judgement. - ANSWER--The RN documents the mental status of a female client who has been hospitalized for several days by court order. The client states"I don't need to be here," and tells the RN that she believes that the t.v talks to her. The RN should document these assessment statements in which section of the mental status exam?
Escort the client out of the bathroom. - ANSWER--An older ale client with schizophrenia is found smearing feces n the bathroom walls of the chronic mental health unit where he resides.What action should the RN implement?
Weight gain of 75 lbs. - ANSWER--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?
Help the client feel safe to decrease anxiety. - ANSWER--A college student who is a victim of a car-jacking presents to the community health center and report increased anxiety. During the interview, what nursing intervention should take the highest priority?
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