MENTAL HESI 7 (75 Questions) (Latest Update) (A Graded) Latest Questions and Complete Solutions
Practice exam
1. A nurse working on a mental health unit
... [Show More] receives a community call from a person who is tearful and states, "I just feel so nervous all of the time. I don't know what to do about my problems. I haven't been able to sleep at night and have hardly eaten for the past 3 or 4 days." The nurse should initiate a referral based on which assessment?
A. Altered thought processes.
B. Moderate levels of anxiety. Correct
C. Inadequate social support.
D. Altered health maintenance.
The nurse should initiate a referral based on anxiety levels (B) and feelings of nervousness that interfere with sleep, appetite, and the inability to solve problems. The client does not report symptoms of (A) or evidence of (C). There is not enough information to initiate a referral based on (D).
2. The nurse is planning discharge for a male client with schizophrenia. The client insists that he is returning to his apartment, although the healthcare provider informed him that he will be moving to a boarding home. What is the most important nursing diagnosis for discharge planning?
A. Ineffective denial related to situational anxiety. Correct
B. Ineffective coping related to inadequate support.
C. Social isolation related to difficult interactions.
D. Self-care deficit related to cognitive impairment.
The best nursing diagnosis is (A) because the client is unable to acknowledge the move to a boarding home. (B, C, and D) are potential nursing diagnoses, but denial is most important because it is a defense mechanism that keeps the client from dealing with his feelings about living arrangements.
3. 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: temperature, 100° F, pulse 100, and BP 142/100. The nurse plans to give the client lorazepam (Ativan) based on which priority nursing diagnosis?
A. Risk for injury related to suicidal ideation.
B. Risk for injury related to alcohol detoxification. Correct
C. Knowledge deficit related to ineffective coping.
D. Health seeking behaviors related to personal crisis.
The most important nursing diagnosis is related to alcohol detoxification (B) because the client has elevated vital signs, a sign of alcohol detoxification. Maintaining client safety related to (A) should be addressed after giving the client Ativan for elevated vital signs secondary to alcohol withdrawal. (C and D) can be addressed when immediate needs for safety are met.
4. When preparing a teaching plan for a client who is to be discharged with a prescription for lithium carbonate (Lithonate), it is most important for the nurse to include which instruction?
A. It may take 3 to 4 weeks to achieve therapeutic effects.
B. Keep your dietary salt intake consistent. Correct
C. Avoid eating aged cheese and chicken liver.
D. Eat foods high in fiber such as whole grain breads.
Lithium's effectiveness is influenced by salt intake (B). Too much salt causes more lithium to be excreted, thereby decreasing the effectiveness of the drug. Too little salt causes less lithium to
be excreted, potentially resulting in toxicity. (A, C, and D) are not specific instructions pertinent to teaching about lithium carbonate (Lithonate).
5. The nurse is preparing to administer phenelzine sulfate (Nardil) to a client on the psychiatric unit. Which complaint related to administration of this drug should the nurse expect this client to make?
A. My mouth feels like cotton. Correct
B. That stuff gives me indigestion.
C. This pill gives me diarrhea.
D. My urine looks pink. [Show Less]