2017 Mental Health PN HESI Specialty V1
The LPN/LVN calls security and has physical restrains applied when a client who was admitted voluntarily
... [Show More] becomes both physically and verbally abusive while demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions? Select all that apply.
1) Libel
2) Battery
3) Assault
4) Slander
5) False Imprisonment
Correct Answer:
2) Battery
3) Assault
5) False Imprisonment
2) A nurse is working with a client who has sought counseling after trying to rescue a neighbor involved in a house fire. Despite the client's efforts, the neighbor died. Which action does the nurse engage in with the client during the working phase of the nurse-client relationship?
1) Exploring the client's ability to function
2) Exploring the client's potential for self-harm
3) Inquiring about the client's perception of appraisal of the neighbor's death
4) Inquiring about and examine the client's feelings that may block adaptive coping
Correct Answer:4) Inquiring about and examine the client's feelings that may block adaptive coping
3) A client who has just been sexually assaulted is calm and quiet. The
nurse analyzes this behavior as indicating which defense mechanism?
1) Denial
2) Projection
3) Rationalization
4) Intellectualization
Correct Answer:1) Denial
4) Unresolved feelings related to loss most likely may be recognized during which phase of the therapeutic nurse-client relationship?
1) Working
2) Trusting
3) Orientation
4) Termination
Correct Answer: 4) Termination
5) Which statement demonstrates the best understanding of the nurse's role regarding ensuring that each client's rights are respected?
1) "Autonomy is the fundamental right of each and every client."
2) "A client's rights are guaranteed by both state and federal laws."
3) "Being respectful and concerned will ensure that I'm attentive to my clients' rights."
4) "Regardless of the client's condition, all nurses have the duty to respect client rights."
Correct Answer: 3) "Being respectful and concerned will ensure that I'm attentive to my clients' rights."
6) A LPN/LVN employed in a mental health unit of a hospital is the leader of a group psychotherapy session. The nurses's role in the termination stage of group development is to:
1) Encourage problem solving
2) Encourage accomplishment of the group's work
3) Acknowledge the contributions of each group member
4) Encourage members to become acquainted with one another
Correct Answer: 3) Acknowledge the contributions of each group member
7) A male client with delirium becomes disoriented and confused in his room at night. The best initial nursing intervention is to:
1) Move the client next to the nurse's station
2) Use an indirect light source and turn off the television
3) Keep the television and a soft light on during the night
4) Play soft music during the night, and maintain a well-lit room
2) Use an indirect light source and turn off the television
8) A client is admitted to a medical nursing unit with a diagnosis of acute blindness. Many tests are performed, and there seems to be no organic reason why this client cannot see. The client became blind after witnessing a hit-and-run car accident, when a family of three was killed. A LPN/LVN suspects that the client may be experiencing a:
1) Psychosis
2) Repression
3) Conversion Disorder
4) Dissociative Disorder
Correct Answer: 3) Conversion Disorder
9) A manic client announces to everyone in the day room that a stripper is coming to perform this evening. When a nurse firmly states that this is inappropriate and will not happen, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, the LPN/LVN determines that the appropriate action would be to:
1) Orient the client to time, person, and place
2) Tell the client that the behavior is inappropriate
3) Escort the manic client to her room, with assistance
4) Tell the client that smoking privileges are revoked for 24 hours Correct Answer: 3) Escort the manic client to her room, with assistance
10) A LPN/LVN observes that a client is pacing, agitated, and presenting aggressive gestures. The client's speech pattern is rapid, and affect is belligerent. Based on these observations, the nurse's immediate priority of care is to:
1) Provide safety for the client and other clients on the unit
2) Provide the clients on the unit with a sense of comfort and safety
3) Assist the staff in caring for the client in a controlled environment
4) Offer the client a less stimulated area to calm down and gain control
Correct Answer: 1) Provide safety for the client and other clients on the unit
11) Select the nursing interventions for a hospitalized client with mania who is exhibiting manipulative behavior. Select all that apply.
1) Communicate expected behaviors to the client
2) Ensure that the client knows that he or she is not in charge of the nursing unit
3) Assist the client in identifying ways of setting limits on personal behaviors
4) Follow through about the consequences of behavior in a non punitive manner
5) Enforce rules and inform the client that he or she will not be allowed to attend therapy groups
6) Be clear with the client regarding the consequences of exceeding limits that have been set regarding behavior
Correct Answer:
1) Communicate expected behaviors to the client
3) Assist the client in identifying ways of setting limits on personal behaviors
4) Follow through about the consequences of behavior in a non punitive manner
6) Be clear with the client regarding the consequences of exceeding limits that have been set regarding behavior
12) A nurse determines that the wife of an alcoholic client is benefitting from attending an Al-Anon group when the nurse hears the wife say:
1) "I no longer feel that I deserve the meetings my husband inflicts on me."
2) "My attendance at the meetings has helped me to see that I provoke my husbands violence."
3) "I enjoy attending the meetings because they get me out of the house and away from my husband."
4) "I can tolerate my husband's destructive behaviors now that I know they are common with alcoholics."
Correct Answer: 1) "I no longer feel that I deserve the meetings my husband inflicts on me."
13) An LPN/LVN is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse determines that this type of crisis is caused by:
1) Witnessing a murder
2) The death of a loved one
3) A fire that destroyed the client's home
4) A recent rape episode experienced by the client Correct Answer: 2) The death of a loved one
14) An LPN/LVN is conducting an initial assessment on a client in crisis. When assessing the client's perception of the precipitating event that lead to the crisis, the appropriate question to ask is:
1) "With whom do you live?"
2) "Who is available to help you?"
3) "What leads you to seek help now?"
4) "What do you usually do to feel better?"
Correct Answer: 3) "What leads you to seek help now?"
15) A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to a nurse "I'm finally cured." The LPN/LVN interprets this behavior as a cue to modify the treatment plan by:
1) Suggesting a reduction of medication
2) Allowing increased "in-room" activities
3) Increasing the level of suicide precautions
4) Allowing the client off-unit privileges as needed
Correct Answer: 3) Increasing the level of suicide precautions
16) An emergency department nurse is caring for an adult client who is a victim of family violence. Which priority instruction would be included in the discharge instructions?
1) Information regarding shelters
2) Instructions regarding calling the police
3) Instructions regarding self-defense classes
4) Explaining the importance of leaving the violent situation Correct Answer: 1) Information regarding shelters
17) A female victim of sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. The appropriate nursing response is which of the following?
1) "You need to try and be realistic. The rape did not just occur."
2) "It will take some time to get over these feelings about your rape."
3) "Tell me more about the incident that causes you to feel like the rape just occurred."
4) "What do you think that you can do to alleviate some of your fears about being raped again?"
Correct Answer: 3) "Tell me more about the incident that causes you to feel like the rape just occurred."
18) A LPN/LVN is preparing to care for a dying client, and several family members are at the client' bedside. Select the therapeutic techniques that the nurse would use when communicating with the family. Select all
that apply.
1) Discourage reminiscing
2) Make decisions for the family
3) Encourage expression of feelings, concerns, and fears
4) Explain everything that is happening to all family members
5) Touch and hold the client's or family member's hands if appropriate
6) Be honest and let the client and family know that they will not be abandoned by the nurse
Correct Answer:
3) Encourage expression of feelings, concerns, and fears 5) Touch and hold the client's or family member's hands if appropriate
6) Be honest and let the client and family know that they will not be abandoned by the nurse
19) A client's medication sheet contains a prescription for sertraline (Zoloft). To ensure safe administration of the medication, a nurse would
administer the dose:
1) On an empty stomach
2) At the same time each evening
3) Evenly spaced around the clock
4) As needed when the client complains of depression Correct Answer: 2) At the same time each evening
20) A LPN/LVN is preforming a follow-up teaching session with a client discharged 1 month ago. The client is taking fluoxetine (Prozac). What information would be important for the nurse to obtain during this client visit regarding the side effects of the medication?
1) Cardiovascular symptoms
2) Gastrointestinal dysfunctions
3) Problems with mouth dryness
4) Problems with excessive sweating
Correct Answer: 2) Gastrointestinal dysfunctions
21) A LVN/LPN is caring for a client with anorexia nervosa. The nurse is monitoring the behavior of the client and understands that a client with anorexia nervosa manages anxiety by:
1) Engaging in immoral acts
2) Always reinforcing self-approval
3) Observing rigid rules and regulations
4) Having the need always to make the right decision Correct Answer: 3) Observing rigid rules and regulations
22) A LPN/LVN is caring for a suicidal client. The appropriate nursing intervention in dealing with this client is to:
1) Demonstrate confidence in the client's ability to deal with stressors
2) Provide hope and reassurance that the problems will resolve themselves
3) Display an attitude of detachment, confrontation, and efficiency
4) Provide authority, action, and participation
Correct Answer: 4) Provide authority, action, and participation
23) A client in a long-term care facility who has multiple sclerosis is embarrassed about the need to use a wheelchair and the muscle spasms that are readily visible in her legs. Which approach is therapeutic in assisting the client to cope?
1) Keep the client in her room as much as possible
2) Assist the client with all activities of daily living
3) Tell the client that many of the people in the facility have these same sorts of problems
4) Encourage and praise perseverance in performing ADLs, and assist the client to dress and groom daily
Correct Answer: 4) Encourage and praise perseverance in performing ADLs, and assist the client to dress and groom daily
24) On admission assessment, the nurse is obtaining subjective data
about a client's sexual and reproductive status. The client states, "I don't want to discuss this; it's private and personal." Which response by the LVN/LPN is the most therapeutic?
1) "I'd hate being asked these sorts of questions too, but it's a necessary part of providing you with the best care."
2) "This is difficult for you to speak about, but I need this information from you in order to perform a complete assessment."
3) "I am a professional registered nurse, and, as such, I'll have you know that all your information is certainly kept confidential."
4) "I know that some of these questions are difficult for you, but, as a professional nurse, I am obligated to respect your confidentiality."
Correct Answer: 4) "I know that some of these questions are difficult for you, but, as a professional nurse, I am obligated to respect your confidentiality."
25) The LPN/LVN should include which information in the nursing plan of care for a client with obsessive-compulsive disorder (OCD)? Select all that apply.
1) The medical diagnosis of the client
2) Individualized goals and objectives
3) Attendance at group therapy sessions
4) Self-care measures to improve hygiene
5) Interruption of all compulsive behaviors
Correct Answer:
2) Individualized goals and objectives
3) Attendance at group therapy sessions
4) Self-care measures to improve hygiene
26) A client in the mental health unit believes that the food is being poisoned. What intervention(s) would be helpful when attempting to encourage the client to eat? Select all that apply.
1) Use open-ended questions to encourage client dialogue
2) Offer opinions about the necessity for adequate nutrition
3) Focus on the client's self-disclosure about food preferences
4) Identify the reasons the client has for not wanting to eat
5) Offer the client food in closed containers, such as in cans that have to be opened
Correct Answer:
1) Use open-ended questions to encourage client dialogue
5) Offer the client food in closed containers, such as in cans that have to be opened
27) A client with a leg amputation is upset about his appearance. The LPN/ LVN intends to address which most closely associated psychosocial problem?
1) Inability to be mobile
2) Isolating self from others
3) Inability to tolerate activity
4) Concern about body persona
Correct Answer: 4) Concern about body persona
28) A client with an eating disorder is planning to attend group meetings with Overeaters Anonymous. The LPN/LVN describes this group to the client, knowing that which finding(s) are characteristic of this form of self-help group? Select all that apply.
1) A common goal is shared by all members
2) Members are required to remain anonymous
3) The leader is a professional mental health care provider
4) Attendance must be prescribed by the health care provider
5) The program is designed to provide support and bring about personal change
6) The group is composed of individuals who are experiencing similar problems
Correct Answer:
1) A common goal is shared by all members
5) The program is designed to provide support and bring about personal change
6) The group is composed of individuals who are experiencing similar problems
29) A client with schizophrenia is experiencing distressful thoughts secondary to paranoia. Which intervention(s) should the LPN/LVN include in the plan of care? Select all that apply.
1) Avoid laughing when near the client
2) Whisper when communicating near the client
3) Increase socialization of the client among his peers
4) Have the client sign a written release of information form
5) Provide food items that are in containers that need to be opened
6) Begin to educate the client about social supports in the community
Correct Answer:
1) Avoid laughing when near the client
5) Provide food items that are in containers that need to be opened
30) A client is preparing to attend at Gamblers Anonymous meeting for the first time. The prototype used by this group is the 12-step program developed by Alcoholics Anonymous. Number in order of priority how the steps would be addressed.
1) Admitting to oneself and to another human being the exact nature of one's wrongs
2) Acknowledging that one is entirely ready to have his or her defects of character removed
3) Admitting that oneself is powerless over gambling and that one's life has become unmanageable
4) Making an effort to practice the 12-step principles in all affairs, and to carry out this message to other compulsive gamblers
5) Making direct amends wherever possible to all people that have been hurt, expect when to do so would further harm them or others
Correct Answer:
3) Admitting that oneself is powerless over gambling and that one's life has become unmanageable
1) Admitting to oneself and to another human being the exact nature of one's wrongs
2) Acknowledging that one is entirely ready to have his or her defects of character removed
5) Making direct amends wherever possible to all people that have been hurt, expect when to do so would further harm them or others
4) Making an effort to practice the 12-step principles in all affairs, and to carry out this message to other compulsive gamblers
31) An outpatient clinic who has been receiving haloperidol (Haldol) for 2 days develops muscular rigidity, altered consciousness, a temperature
of 103, and trouble breathing on day 3. The LPN/LVN interest these findings as indicating which of the following.
1) Neuroleptic Malignant Syndrome
2) Tardive dyskinesia
3) Extrapyramidal adverse effects
4) Drug-induced parksonism
Correct Answer: 1) Neuroleptic Malignant Syndrome
32) A newly admitted client describes her mission in life as one of saving her son by eliminating the "provocative sluts" of the world. There are several attractive young women on the unit. What should the LPN/LVN do first?
1) Ask the client for her definition of "provocative sluts"
2) Ask the young female clients on the unit to dress less provocatively
3) Ask the client to discuss her concerns in the next group session
4) Ask the client to inform the staff if she has negative thoughts about other clients
Correct Answer: 4) Ask the client to inform the staff if she has negative thoughts about other clients
33) The wife of a client diagnosed with paranoid schizophrenia visits 2 days after her husband;s admission and states to the nurse, "Why isn' he
eating? He's still talking about his food being poisoning." With of the following appraisals by the LPN/LVN is most accurate?
1) The wife's inquiry is reasonable
2) Education about her husband's medication is needed
3) Her expectations of her husband are realistic
4) An increase in the client's medication is needed
Correct Answer: 2) Education about her husband's medication is needed
34) A client states that she hears God's voice telling her that she has sinned and needs to punish herself. Which response by the LPN/LVN is most important?
1) "How do you think you will be punished?"
2) "Please tell staff when you think you need to punish yourself."
3) "What exactly do you think you have done to be punished?"
4) "Let's talk about your strengths"
Correct Answer: 2) "Please tell staff when you think you need to punish yourself."
35) A client diagnosed with paranoid schizophrenia is still withdrawn, unkept, and unmotivated to get out of bed. A mental health aide asks the nurse why the client is this way after being on fluphenazine (Prolix) 10 mg for 7 days. The LPN/LVN should tell the health aide:
1) "Prolixin is the most effective with positive symptoms of schizophrenia."
2) "The client will be less withdrawn and unmotivated when the Prolixin takes effect."
3) "The client's Prolix dose probably needs to be increased again."
4) "Lack of motivation is a common side effect of the Prolixin."
Correct Answer: 1) "Prolixin is the most effective with positive symptoms of schizophrenia."
36) A client is being successfully treated with clozapine (Clozaril). Which of the following statements by the client reflects a need for further teaching about managing the drug's adverse effects?
1) "If I eat too many fruits, I'll get constipated."
2) I need to take the medicine with food to avoid nausea."
3) "I have to get up slowly so I don't get dizzy."
4) "Sometimes I have to push myself because I'm sleepy." Correct Answer: 1) "If I eat too many fruits, I'll get constipated."
37) The LPN/LVN is assessing a client who is taking an antipsychotic medication. Which of the following symptoms is uniquely indicative of neuroleptic malignant syndrome (NMS) and requires immediate attention?
1) Very high temperature
2) Muscular rigidity
3) Tremors
4) Altered consciousness
Correct Answer: 1) Very high temperature
38) A client diagnosed with undifferentiated schizophrenia is being discharged on aripiprazole (Ability) 5 mg every night. When developing the teaching plan about the most common adverse effects, which of the following should the nurse include? Select all that apply.
1) Headaches that will subside in a few weeks
2) Transient mild anxiety
3) Insomnia
4) Torticollis
Correct Answer:
4) Pill rolling movements
1) Headaches that will subside in a few weeks
2) Transient mild anxiety
3) Insomnia
39) An elderly client was prescribed Ativan 1 mg three times a day to help calm her anxiety after her husband's death. The next day the client calls her daughter asking when she is picking her up to go to the graveside. The client says she has been walking up and down the driveway for the past hour waiting for her [Show Less]