HESI MENTAL FINAL REVIEW with Answers
1. A schizophrenic client who is taking fluphenazine decanoate (Prolixin decanoate) is being discharged in the... [Show More] morning. A repeat dose of medication is scheduled for 20 days after discharge. The client tells the nurse about a planned vacation and will return in 18 days. Which statement by the client indicates to the nurse a need for health teaching?
A. A."I am going to have lots of fun at the beach and plenty of time in the sun."
B. "While I am on vacation, I will not eat or drink anything that contains alcohol."
C. "I will notify the health care provider if I have a sore throat or flulike symptoms."
D. "I will continue to take my benztropine mesylate (Cogentin) every day."
2. A client believes that his health care provider is an FBI agent and that his apartment is a site for slave trading. The client believes that the FBI has cameras in the apartment, so it is not safe to return there. Based on these symptoms, which class of medication is most likely to find to be prescribed for this client?
A. Antianxiety medication
B. Mood stabilizer
3. A client who is being treated with lithium carbonate for manic depression begins to develop diarrhea, vomiting, and drowsiness. Which action should the nurse take?
A. Notify the health care provider immediately and force fluids.
B. Prior to giving the next dose, notify the health care provider of these symptoms.
C. Record the symptoms and continue with medication as prescribed.
D. Hold the medication and refuse to administer additional doses.
4. Which behavior indicates to the nurse that a client with paranoid ideas is improving?
A. Arrives on time for all activities
B. Talks more openly about plans to protect his possessions
C. Aggressively uses the punching bag in the gym
D. Discusses his feelings of anxiety with the nurse
5. Clients are preparing to leave the mental health unit for an outdoor smoke break. A client on constant observation cannot leave and becomes agitated and demands to smoke a cigarette. Which action should the nurse take first?
A. Remind the client to wear the nicotine (NicoDerm) patch.
B. Determine if the client still needs constant observation.
C. Encourage the client to attend the smoking cessation group.
D. Explain that clients on constant observation cannot smoke.
6. Physical examination of a 6-year-old boy reveals several bite marks in various locations on his body. X-ray examination reveals healed fractures of the ribs. The mother tells the nurse that her child is always having accidents. Which initial response by the nurse would be most appropriate?
A. "I need to tell the health care provider about your child's tendency to be accident-prone."
B. "Tell me more about these accidents that your child has been having."
C. "I need to report these injuries to the authorities because they do not seem accidental."
D. "Boys this age always seem to require more supervision and can be quite accident-prone."
7. When planning care for the client undergoing electroconvulsive therapy (ECT), which equipment should the nurse make available? (Select all that apply.)
B. Suction equipment
C. Continuous passive range-of-motion (CPM) machine
D. Crash cart
E. Chest tube drainage system
8. During a home visit, a client with schizophrenia reports hearing voices that tell the client to walk in the middle of the street. The nurse records several statements made by the client. Based on which statement should the nurse determine that the client needs hospitalization?
A. "Sometimes I take an extra one of my pills when I hear the voices."
B. "The voices are louder when I forget to take my medication. "
C. "No matter what I do, I cannot make the voices go away. "
D. "I just try to tell the voices to stop when they bother me. "
9. A 27-year-old client is admitted to the psychiatric hospital with a diagnosis of bipolar disorder, manic phase. The client is demanding and active. Which intervention should the nurse include in this client's plan of care?
A. Schedule the client to attend various group activities.
B. Reinforce the client's ability to make decisions.
C. Encourage the client to identify feelings of anger.
D. Provide a structured environment with little stimuli.
10. An individual with a known history of alcohol abuse is admitted for emergency surgery following a motor vehicle collision. The nurse includes in the client's plan of care, "Observe for signs of delirium tremens." Which early signs indicate that the client is beginning to have delirium tremens?
A. Abdominal cramping and watery eyes
B. Depression and fatigue
C. Restlessness and confusion
D. Hostility and anger
11. A 25-year-old client has suffered extensive burns and is crying during dressing change treatment. The client tells the nurse, "Please let me die. Why are you all torturing me like this? I just want to die." Which response by the nurse is best?
A. "We aren't torturing you. These treatments are necessary to prevent a terrible infection."
B. I know these treatments must seem like torture to you, but we want to help you recover."
C. "You have so much to live for, and all of your family members want you to live."
D. "Would you like me to call the chaplain so that you can discuss your feelings privately?"
12. A woman brings her 48-year-old husband to the outpatient psychiatric unit and tells the nurse that he has been sleepwalking, cannot remember who he is, and exhibits multiple personalities. These behaviors are often associated with which condition?
A. Dissociative disorder
B. Obsessive-compulsive disorder
C. Panic disorder
D. Posttraumatic stress syndrome
13. An 8-year-old child is seen in the clinic with a green vaginal discharge. Which action is most important for the nurse to implement?
A. Assess the child's blood pressure.
B. Counsel the child to wear cotton underwear.
C. Report as suspected child abuse.
D. Determine if the child takes bubble baths.
14. The nurse develops a plan of care for a client with symptoms of paranoia and psychosis. The priority nursing diagnosis is Impaired social interactions related to inability to trust. Which intervention is most important for the nurse to implement?
A. Greet the client by first name during each social interaction.
B. Determine if the client is experiencing auditory hallucinations.
C. Introduce the client to peers on the unit as soon as possible.
D. Assign the client to a group about developing social skills.
15- A 22-year-old client is admitted to the psychiatric unit from the medical unit following a suicide attempt with an overdose of diazepam (Valium). When developing the nursing care plan for this client, which intervention would be most important for the nurse to include?
A. Assist client to focus on personal strengths.
B. Set limits on self-defacing comments.
C. Remind the client of daily activities in the milieu.
D. Assist the client to identify why he or she was self-destructive.
16- The nurse is assessing a young client admitted to the psychiatric unit for acute depression related to a recent divorce. Which statement is most indicative of a client suffering from depression?
A. "I'm not very pretty or likeable."
B. "I've lost 20 pounds in the past month."
C. "I like to keep things to myself."
D. "I think everyone is out to get me."
17- The nurse notes multiple burns on the arms and chest of a 2-year-old Vietnamese child who is being treated for dehydration. When questioned, the child's father states that he treated the child's vomiting with the cultural practice termed coining, which resulted in burned areas. Which expected outcome statement has the highest priority?
A. The child will be protected from further harm.
B. The family's cultural values will be respected.
C. The parents will express regret at harming their child.
D. The parents will demonstrate an ability to care for burn wounds.
18- A 33-year-old client is admitted to a psychiatric facility with a medical diagnosis of major depression. When the nurse is assigning the client to a room, which roommate is best for this client?
A. A 35-year-old client who recently attempted suicide
B. A manic client who has started lithium carbonate treatment
C. A client who is bipolar and is pacing the floor while telling jokes to everyone
D. A paranoid client who believes that the staff is trying to poison the food
A- client who recently retired is admitted to the psychiatric inpatient unit with a diagnosis of major depression. The initial nursing care plan includes the goal, "Assist client to express feelings of guilt." What is true about the goal statement referring to the client's depression?
A. Implementation of the goal should be deferred until further data can be gathered.
B. The depression will dissipate once the client becomes accustomed to retirement.
C. Depressed clients may be unaware of guilt feelings and should be encouraged to increase self-awareness.
D. Nursing goals should be approved by the treatment team before they are initiated.
20- At the first meeting of a group at a daycare center for older adults, the nurse asks one of the members what kinds of things the client would like to do with the group. The older adult shrugs and says, "You tell me. You're the leader." What would be the best response for the nurse to make?
A. "Yes, I am the leader today. Would you like to be the leader tomorrow?"
B. "Yes, I will be leading this group. What would you like to accomplish?"
C. "Yes, I have been assigned to lead this group. I will be here for the next 6 weeks."
D. "Yes, I am the leader. You seem angry about not being the leader yourself."
21- On admission, a depressed client tells the nurse, "I can't eat because my tongue is rubber." Which is the best action for the nurse to implement
A. "Provide packaged foods for the client to eat.
B. Begin the client on total parenteral nutritional (TPN) therapy.
C. Provide a well-balanced liquid diet for the client.
D. No action is necessary because the client will eat when hungry.
22- The registered nurse observes a client who is admitted to the mental health unit and identifies that the client is talking continuously, using words that rhyme but that have no context or relationship with one topic to the next in the conversation. This client's behavior and thought processes are consistent with which syndrome?
D) Chronic brain syndrome.
23- The nurse is leading a "current events group" with chronic psychiatric clients. One group member states, "Saddam Hussein was my nurse during my last hospitalization. He was a very mean nurse and wasn't nice to me." Which response is best for the nurse to make?
A) Saddam Hussein was not your nurse.
B) What did he do to you that was so mean?
C) I didn't know that Saddam Hussein was a nurse.
D) I agree that Saddam Hussein is not a very nice man
24. A 35-year-old male client who has been hospitalized for two weeks for chronic paranoia continues to state that someone is trying to steal his clothing. Which action should the nurse implement?
A) Encourage the client to actively participate in assigned activities on the unit.
B) Place a lock on the client's closet.
C) Ignore the client's paranoid ideation to extinguish these behaviors.
D) Explain to the client that his suspicions are false.
25- The nurse should include which interventions in the plan of care for a severely depressed client with neurovegetative symptoms? (Select all that apply.)
A) Permit rest periods as needed.
B) Speaking slowly and simply.
C) Place the client on suicide precautions.
D) Allow the client extra time to complete tasks.
E) Observe and encourage food and fluid intake.
F) Encourage mild exercise and short walks on the unit.
26. The nurse is planning care for a 32-year-old male client diagnosed with HIV infection who has a history of chronic depression. Recently, the client's viral load has begun to increase rather than decrease despite his adherence to the HIV drug regimen. What should the nurse do first while taking the client's history upon admission to the hospital?
A) Determine if the client attends a support group weekly.
B) Hold all antidepressant medications until further notice.
C) Ask the client if he takes St. John's Wort routinely.
D) Have the client describe any recent changes [Show Less]