PN Hesi Mental Health Specialty V1 fall 2017
1. The LPN/LVN calls security and has physical restrains applied when a client who was admitted voluntari... [Show More] ly 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.
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
3) A client who has just been sexually assaulted is calm and quiet. The
nurse analyzes this behavior as indicating which defense mechanism?
4) Unresolved feelings related to loss most likely may be recognized during which phase of the therapeutic nurse-client relationship?
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."
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
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
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:
3) Conversion Disorder
4) Dissociative 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
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
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
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."
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
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?"
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
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
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?"
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
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
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
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
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
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
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
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."
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
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
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
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
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
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
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
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
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
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"
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."
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."
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
4) Altered consciousness
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
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 daughter. Noting the client's agitation, hyperactivity, and instance, the daughter calls the nurse to report her mother's behavior. Which of the following would the nurse suspect as the cause of the mother's behavior and what action should she
1) The client is manic and may need a sleeping pill
2) The client is experiencing a medication interaction and should go to the ED
3) The client is experiencing a paradoxical reaction to the Ativan and should stop the new medication immediately
4) The client is overcome by grief and probably needs an antidepressant
40) When caring for a client who has overdosed on PCP, the nurse should be especially caucus about which of the following client behaviors?
1) Visual hallucinations
2) Violent behavior
3) Bizarre behavior
4) Loud screaming
41) A client who is being treated with lithium carbonate for bipolar disorder develops diarrhea, vomiting, and drowsiness. What action should the LPN/LVN take?
1) Notify the healthcare provider immediately and prepare for administration of an antidote.
2) Notify the healthcare provider of the symptoms prior to the next administration of the drug.
3) Record the symptoms as normal side effects and continue administration of the prescribed dosage.
4) Hold the medication and refuse to administer additional amounts of the drug.
42) The parents of a 14-year-old boy bring their son to the hospital. He is lethargic, but responsive. The mother states, "I think he took some of
my pain pills." During initial assessment of the teenager, what information is most important for the nurse to obtain from the parents?
1) If he has seemed depressed recently.
2) If a drug overdose has ever occurred before.
3) If he might have taken any other drugs.
4) If he has a desire to quit taking drugs.
43) The wife of a male client recently diagnosed with schizophrenia asks the nurse, "What exactly is schizophrenia? Is my husband all right?" Which response is best for the LPN/LVN to provide to this family member?
1) It sounds like you're worried about your husband. Let's sit down and talk.
2) It is a chemical imbalance in the brain that causes disorganized thinking.
3) Your husband will be just fine if he takes his medications regularly.
4) I think you should talk to your husband's psychologist about this question.
44) The community health nurse talks to a male client who has bipolar disorder. The client explains that he sleeps 4 to 5 hours a night and is working with his partner to start two new businesses and build an empire. The client stopped taking his medications several days ago. What nursing problem has the highest priority?
1) Excessive work activity.
2) Decreased need for sleep.
3) Medication management.
4) Inflated self-esteem.
45) At a support meeting of parents of a teenager with polysubstance
dependency, a parent states, "Each time my son tries to quit taking drugs, he gets so depressed that I'm afraid he will commit suicide." The nurse's response should be based on which information?
1) Addiction is a chronic, incurable disease.
2) Tolerance to the effects of drugs causes feelings of depression.
3) Feelings of depression frequently lead to drug abuse and addiction.
4) Careful monitoring should be provided during withdrawal from the drugs.
46) The LPN/LVN observes a female client with schizophrenia watching the news on TV. She begins to laugh softly and says, "Yes, my love, I'll do it." When the nurse questions the client about her comment she states, "The news commentator is my lover and he speaks to me each evening. Only I can understand what he says." What is the best response for the nurse to make?
1) What do you believe the news commentator said to you?
2) Let's watch news on a different television channel.
3) Does the news commentator have plans to harm you or others?
4) The news commentator is not talking to you.
47) At the first meeting of a group of older adults at a daycare center for the elderly, the LPN/LVN asks one of the members what kinds of things she would like to do with the group. The older woman shrugs her shoulders and says, "You tell me, you're the leader." What is the best response for the nurse to make?
1) Yes, I am the leader today. Would you like to be the leader tomorrow?
2) Yes, I will be leading this group. What would you like to accomplish during this time?
3) Yes, I have been assigned to be the leader of this group. I will be here for the next six weeks.
4) Yes, I am the leader. You seem angry about not being the leader
48) The LPN/LVN 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?
1) Ineffective denial related to situational anxiety.
2) Ineffective coping related to inadequate support.
3) Social isolation related to difficult interactions.
4) Self-care deficit related to cognitive impairment.
49) 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?
1) Hamburger, French fries, and chocolate milkshake.
2) Liver and onions, broccoli, and decaffeinated coffee.
3) Pepperoni and cheese pizza, tossed salad, and a soft drink.
4) Roast beef, baked potato with butter, and iced tea.
50) An elderly female client with advanced dementia is admitted to the hospital with a fractured hip. The client repeatedly tells the staff, "Take me home. I want my Mommy." Which response is best for the LPN/ LVN to provide?
1) Orient the client to the time, place, and person.
2) Tell the client that the nurse is there and will help her.
3) Remind the client that her mother is no longer living.
4) Explain the seriousness of her injury and need for hospitalization.
51) The LPN/LVN is assessing a client's intelligence. Which factor should the nurse remember during this part of the mental status exam?
1) Acute psychiatric illnesses impair intelligence.
2) Intelligence is influenced by social and cultural beliefs.
3) Poor concentration skills suggests limited intelligence.
4) The inability to think abstractly indicates limited intelligence.
52) The LPN/LVN should include which interventions in the plan of care for a severely depressed client with neurovegetative symptoms? (Select all that apply.)
1) Permit rest periods as needed.
2) Speaking slowly and simply.
3) Place the client on suicide precautions.
4) Allow the client extra time to complete tasks.
5) Observe and encourage food and fluid intake.
6) Encourage mild exercise and short walks on the unit
53) An 86-year-old female client with Alzheimer's disease is wandering the busy halls of the extended care facility and asks the nurse, "Where should I stand for the parade?" Which response is best for the LPN/ LVN to provide?
1) Anywhere you want to stand as long as you do not get hurt by those in the parade.
2) You are confused because of all the activity in the hall. There is no parade.
3) Let us go back to the activity room and see what is going on in there.
4) Remember I told you that this is a nursing home and I am your nurse.
54) Based on non-compliance with the medication regimen, an adult client with a medical diagnosis of substance abuse and schizophrenia was recently switched from oral fluphenazine HCl (Prolixin) to IM fluphenazine decanoate (Prolixin Decanoate). What is most important to teach the client and family about this change in medication regimen?
1) Signs and symptoms of extrapyramidal effects (EPS).
2) Information about substance abuse and schizophrenia.
3) The effects of alcohol and drug interaction.
4) The availability of support groups for those with dual diagnoses.
55) An adult male client who was admitted to the mental health unit yesterday tells the nurse that microchips were planted in his head for military surveillance of his every move. Which response is best for the LPN/LVN to provide?
1) You are in the hospital, and I am the nurse caring for you.
2) It must be difficult for you to control your anxious feelings.
3) Go to occupational therapy and start a project.
4) You are not in a war area now; this is the United States. [Show Less]