HESI Psychiatric/Mental Health Practice Exam
1) The nurse should include which interventions in the plan of care for a severely depressed client with
... [Show More] neurovegetative symptoms? (Select all that apply.)
o Permit rest periods as needed.
o Speaking slowly and simply.
o Place the client on suicide precautions.
o Observe and encourage food and fluid intake.
o Encourage vigorous exercise and long walks on the unit.
• Neurovegetative symptoms that accompany the mood disorder of depression include physiological disruptions, such as anorexia, constipation, sleep disturbance, and psychomotor retardation. The client's plan of care should include measures that promote the client's comfort and well-being, such as rest, nutrition, suicide precautions, and simple communications. Vigorous exercise and long walks are not indicated for clients in a neurovegetative state.
2) Which diet selection by a client who is depressed and taking the MAO inhibitor tranylcypromine sulfate (Parnate) indicates to the nurse that the client understands the dietary restrictions imposed by this medication regimen?
o Hamburger, French fries, and chocolate milkshake.
o Liver and onions, broccoli, and decaffeinated coffee.
o Pepperoni and cheese pizza, tossed salad, and a soft drink.
o Roast beef, baked potato with butter, and iced tea.
• Foods with tyramine interact with MAOI antidepressant, such as Parnate, and can cause a hypertensive crisis that is life-threatening. Roast beef, potatoes, butter, and tea do not contain tyramine. The other selections contain tyramine and should be avoided by the client who is taking Parnate.
3) An older male client in the intensive care unit who has been oriented suddenly becomes disoriented and fearful. Assessment of vital signs and other physical parameters reveal no significant change and the nurse formulates the client's problem as confusion related to ICU psychosis. Which intervention is most important for the nurse implement?
o Move all machines away from the client's immediate area.
o Attempt to allay the client's fears by explaining the etiology of confusion.
o Cluster care so brief periods of rest can be scheduled during the day.
o Extend visitation times for family and friends.
• The critical care environment confronts clients with an environment which is stressful and heightened by treatment modalities that may prove to be lifesaving. These stressors can result in isolation or sensory overload that leads to confusion. The best intervention is to cluster care to provide the client with uninterrupted rest periods. The other actions may not be possible.
4) A male client is admitted to the psychiatric unit with a medical diagnosis of paranoid schizophrenia. During the admission procedure, the client looks up and states, "No, it's not MY fault. You can't blame me. I didn't kill him, you did." What action is best for the nurse to take?
o Reassure the client by telling him that his fear of the admission procedure is to be expected.
o Tell the client that no one is accusing him of murder and remind him that the hospital is a safe place.
o Assess the content of the hallucinations by asking the client what he is hearing.
o Ignore the behavior and make no response at all to his delusional statements.
• Further assessment is indicated and the nurse should obtain information about what the client believes the voices are saying--they may be telling him to kill himself or the nurse. The other actions are not indicated.
5) The nurse is assessing a client's intelligence. Which factor should the nurse remember during this part of the mental status exam?
o Acute psychiatric illnesses impair intelligence.
o Intelligence is influenced by social and cultural beliefs.
o Poor concentration skills suggests limited intelligence.
o The inability to think abstractly indicates limited intelligence.
• Social and cultural beliefs have significant impact on intelligence. The other factors do not necessarily suggest limited intelligence.
6) A young adult male client, diagnosed with paranoid schizophrenia, believes that world is trying to poison him. What intervention should the nurse include in this client's plan of care?
o Remind the client that his suspicions are not true.
o Ask one nurse to spend time with the client daily.
o Encourage the client to participate in group activities.
o Assign the client to a room closest to the activity room.
• A client with paranoid schizophrenia has difficulty with trust and developing a trusting relationships, the plan of care should include providing one nurse to spend time with the client daily, which is likely to be therapeutic for this client. The other actions are too stressful for the client and not indicated.
7) The nurse is assessing a client who is admitted with a diagnosis of depression. Which findings is characteristic of depression?
o Grandiose ideation.
o Self-destructive thoughts.
o Suspiciousness of others.
o A negative view of self and the future.
• Negative self-image and feelings of hopelessness about the future are specific findings in depression. The other findings are not the underlying manifestations in depression.
8) The nurse is taking a history for a female client who is requesting a routine female exam. Which assessment finding requires follow-up?
o Menstruation onset at age 9.
o Contraceptive method includes condoms only.
o Menstrual cycle occurs every 35 days.
o "Black-out" after one drink last night on a date.
• A "black-out" typically occurs after ingestion of alcohol beverages that the client has no recall of experiences or one's behavior and is indicative of high blood alcohol levels. The client's experience of a "black-out" after one drink is suspicious of the client receiving a "date rape" drug, such as flunitrazepam ("Rohypnol"), and needs additional follow-up. The other findings do not need follow-up at this time.
9) The nurse is preparing to administer phenelzine sulfate (Nardil) to a client on the psychiatric unit. Which side effect reported by the client is related to administration of this drug?
o My mouth feels like cotton.
o That stuff gives me indigestion.
o This pill gives me diarrhea.
o My urine looks pink.
• A dry mouth is an anticholinergic response that is an expected side effect of MAO inhibitors, such as phenelzine sulfate (Nardil). The other subjective reports are not related to this medication.
10) An adult female client is admitted to the psychiatric hospital with a diagnosis of bipolar disorder, manic phase. She is demanding and active. Which intervention should the nurse include in this client's plan of care?
o Schedule her to attend various group activities.
o Reinforce her ability to make her own decisions.
o Encourage her to identify feelings of anger.
o Provide a structured environment with little stimuli.
• Clients in the manic phase of a bipolar disorder require decreased stimuli and a structured environment. Planning noncompetitive activities that can be carried out alone help to reduce stimuli. Impulsive decision- making is characteristic of clients with bipolar disorder and require the nurse to intervene when a client is making decisions. Anger is often repressed during depression, not mania.
11) The nurse is conducting discharge teaching for a client with schizophrenia who plans to live in a group home. Which statement is most indicative of the need for careful follow-up after discharge?
o Crickets are a good source of protein.
o I have not heard any voices for a week.
o Only my belief in God can help me.
o Sometimes I have a hard time sitting still.
• The most frequent cause of increased symptoms in clients who are psychotic is noncompliance with the medication regimen. If the client believes that "God alone" can help, which may be a delusion and not faith-based, the client may discontinue the prescribed medication. The other client statements do not pose the greatest threat to the client's prognosis.
12) An adult female client is admitted to the psychiatric unit for evaluation. Her husband states that she has been reluctant to leave home for the last six months. The client has not gone to work for a month and has been terminated from her job. She has not left the house since that time. Which condition is this client likely manifesting?
o Claustrophobia.
o Acrophobia.
o Agoraphobia.
o Post-traumatic stress disorder.
• Agoraphobia is the fear of crowds or being in an open place. The other anxiety and phobic conditions are not manifested by a fear of leaving a protected environment, such as home.
13) A male client is admitted to the mental health unit because he was feeling depressed about the loss of his wife and job. The client has a history of alcohol dependency and admits that he was drinking alcohol 12 hours ago. Vital signs are: temperature100o F, pulse 100 beats/minute, and blood pressure 142/100. The nurse plans to give the client lorazepam (Ativan) based on which priority client problem?
o Risk for injury related to suicidal ideation.
o Risk for injury related to alcohol detoxification.
o Knowledge deficit related to ineffective coping.
o Health seeking behaviors related to personal crisis.
• The most important client problem is alcohol detoxification because the client has elevated vital signs, a sign of alcohol detoxification. Maintaining client safety is the priority, and the risk for injury should be addressed after giving the client Ativan for elevated vital signs secondary to alcohol withdrawal. The other problems are not the priority.
14) A young adult female client with a diagnosis of anorexia nervosa wants to help serve dinner trays to other clients on a psychiatric unit. What action should the nurse take?
o Encourage the client's self-motivation by asking her to pass trays for the rest of the week.
o Provide an additional challenge by asking the client to help feed the older clients.
o Suggest another way for this client to participate in the unit's activities. [Show Less]