ASN 100 Mental Health Hesi Review Questions and Answers Explained and Rationalized

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QUES: a 30 year old sales manager tells the nurse "i am thinking about a job change. i don't feel like i am living up to my potential." which of maslows developmental stages is the sales manager atte... mpting to achieve QUES: the 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 have no context or relationship with one topic to the next in the conversation. This clients behavior and thought processes are consistent with which syndrome QUES: a homeless person who is in the manic phase of bipolar disorder is admitted to the mental health unit.. which lab finding obtained on admission is most important for the nurse to report to the HCP QUES: 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 nurse to provide QUES: the nurse is assessing a clients intelligence.. which factor should the nurse remember during this part of the mental status exam QUES: 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 nurses response should be based on which information QUES: 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 nurse to provide QUES: a young adult male client, diagnosed with paranoid schizophrenia, believes that the world is trying to poison him.. what intervention should the nurse include in this clients plan of care QUES: the community health nurse talks to a male client who has bipolar disorder.. the client explains that he sleeps 4-5 hours a night and is working with his partner to start two new businesses and build an empire.. the client stopped taking his meds several days ago.. what nursing problem has the highest priority QUES: a female client with OCD is describing her obsessions and compulsions and asks the nurse why these make her feel safer.. what information should the nurse include in this clients teaching plan QUES: The nurse observes a female client with schizophrenia watching the news on TV.. she begins to laugh softly and says, "yes my love ill 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 what do you believe the news commentator said to you: QUES: a 40 year old male client diagnosed with schizophrenia and alcohol dependence has not had any visitors or phone calls since admission.. he reports he has no family that cares about him and was living on the streets prior to this admission.. according to ericksons theory of psychosocial development, which stage is the client in at this time QUES: 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 QUES: a male client with mental illness and substance dependency tells the mental health nurse that he has started using illegal drugs again and wants to seek treatment.. since he has a dual diagnosis, which person is best for the nurse to refer this client to first QUES: a male client is admitted to a mental health unit on friday afternoon and is very upset on sunday because he has not had the opportunity to talk with the HCP.. which response is best for the nurse to provide this client QUES: a female client refuses to take an oral hypoglycemic agent bc she believes that the drug is being administered as part of an elaborate plan by the mafia to harm her.. which nursing intervention is most important to include in this clients plan of care QUES: 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, its not my fault, you can't blame me, i didn't kill him, you did".. what action is best for the nurse to take QUES: an 86 year old female client with alzheimers 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 nurse to provide QUES: physical exam of a 6 year old reveals several bite marks in various locations on his body.. x-ray exam 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 QUES: a child is brought to the emergency room with a broken arm.. bc of other injuries, the nurse suspects the child may be a victim of abuse.. when the nurse tries to give the child an injection, the childs mother becomes very loud and shouts "i won't leave my son! don't you touch him! you'll hurt my child!".. what is the best interpretation of the mothers statements.. the mother is QUES: a 38 year old female client is admitted with a diagnosis of paranoid schizophrenia.. when her tray is brought to her, she refuses to eat and tells the nurse, "i know you are trying to poison me with that food".. which response is most appropriate for the nurse to make QUES: a 25 year old female client has been particularly restless and the nurse finds her trying to leave the psychiatric unit.. she tells the nurse "please let me go! i must leave bc the secret police are after me".. which response is best for the nurse to make QUES: a 45 year old male client tells the nurse that he used to believe that he was jesus christ, but now he knows he is not.. which response is best for the nurse to make QUES: a nurse working in the emergency room of a children's hospital admits a child whose injuries could have resulted from abuse.. which statement most accurately describes the nurses responsibility in cases of suspected child abuse QUES: a client who is being treated with lithium carbonate for bipolar disorder develops diarrhea, vomiting, and drowsiness.. what action should the nurse take QUES: a client on the psychiatric unit appears to imitate a certain nurse on the unit.. the client seeks out this particular nurse and imitates her mannerisms.. the nurse knows that the client is using which defense mechanism QUES: a client, who is on a 30 day commitment to a drug rehabilitation unit, asks the nurse if he can go for a walk on the grounds of the treatment center.. when he is told that his privileges do not include walking on the grounds, the client becomes verbally abusive.. which approach should the nurse use QUES: the nurse is planning the care for a 32 year old male client with acute depression.. which nursing intervention best helps this client deal with his depression QUES: an anxious client expressing a fear of people and open places is admitted to the psychiatric unit.. what is the most effective way for the nurse to assist this client QUES: a client with bipolar disorder on the mental health unit becomes loud, and shouts at one of the nurses "you fat tub of lard! get something done around here!".. what is the best initial action for the nurse to take QUES: 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 QUES: on admission, a highly anxious client is described as delusional.. the nurse understands that delusions are most likely to occur with which class of disorder QUES: a client is admitted with a diagnosis of depression.. the nurse knows that which characteristic is most indicative of depression QUES:a 45 year old 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.. this client is displaying symptoms of what condition QUES: a client who has been admitted to the psychiatric unit tells the nurse "my problems are so bad that no one can help me".. which response is best for the nurse to make QUES: a woman brings her 48 year old husband to the outpatient psychiatric unit and describes his behavior to the admitting nurse.. she states that he has been sleepwalking, cannot remember who he is, and exhibits multiple personalities.. the nurse knows that these behaviors are often associated with QUES: a 27 year old 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 clients plan of care QUES: the nurse plans to help an 18 year old female mentally retarded client ambulate the first postoperative day after an appendectomy.. when the nurse tells the client it is time to get out of bed, the client becomes angry and tells the nurse "get out of here! ill get up when I'm ready!".. which response is best for the nurse to make QUES: a 46 year old female client has been on antipsychotic neuroleptics for the past three days.. she has had a decrease in psychotic behavior and appears to be responding well to the medication.. on the fourth day, the clients blood pressure increases, she becomes pale and febrile, and demonstrates muscular rigidity.. which action should the nurse initiate QUES: a 35 year old male client on the psychiatric ward of a general hospital believes that someone is trying to poison him.. the nurse understands that a clients delusions are most likely related to his QUES: a client who is diagnosed with schizophrenia is admitted to the hospital.. the nurse assesses the clients mental status.. which assessment finding is most characteristic of a client with schizophrenia QUES: 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 QUES: a 52 year old male client in the ICU who has been oriented suddenly becomes disoriented and fearful.. assessment of VS and other physical parameters reveal no significant change and the nurse formulates the diagnosis "confusion related to ICU psychosis".. which intervention is best to implement QUES: a 19 year old 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 QUES: a male client with schizophrenia who is taking fluphenazine decanoate (prolixin decanoate) is being discharged in the morning.. a repeat dose of medication is scheduled for 20 days after discharge.. the client tells the nurse that he is going on vacation in the bahamas and will return in 18 days.. which statement by the client indicates a need for health teaching when i return from my tropical island vacation, QUES: the nurse is leading a "current evens group" with chronic psychiatric clients.. one group member states "clara barton was my nurse during my last hospitalization.. she was a very mean nurse and wasn't nice to me".. which response is best for the nurse to make QUES: an adult client with a medical diagnosis of substance abuse and schizophrenia was recently switched from oral fluphenazine HCl to IM fluphenazine decanoate.. what is most important to teach the client and family about this change in medication regimen QUES: the nurse should hold the next scheduled dose of a clients haloperidol (Haldol) based on which assessment finding QUES: within several days of hospitalization, a client is repeatedly washing the top of the same table.. which intervention is best for the nurse to implement to help the client cope with anxiety related to this behavior QUES: a female client with depression attends group and states that she sometimes misses her medication appointments bc she feels very anxious about riding the bus.. which statement is the nurses best response what are some ways that you can cope with your anxiety: QUES: a nurse working on a mental health unit 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 havent been able to sleep at night and have hardly eaten for the past 3-4 days".. the nurse should initiate a referral based on which assessment QUES: the nurse is planning discharge for a male client with schizophrenia.. the client insists that he is returning to his apartment, although the HCP informed him that he will be moving to a boarding home.. what is the most important nursing diagnosis for discharge planning QUES: a male client is admitted to the mental health unit bc 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.. VS are T 100, P 100, BP 142/100.. the nurse plans to give the client lorazepam (Ativan) based on which priority nursing diagnosis QUES: 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 QUES: 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 QUES: a client is receiving substitution therapy during withdrawal from benzodiazepines.. which expected outcome statement has the highest priority when planning nursing care QUES: a client who is known to abuse drugs is admitted to the psychiatric unit.. which medication should the nurse anticipate administering to a client who is exhibiting benzodiazepine withdrawal symptoms QUES: a 22 year old male client is admitted to the emergency center following a suicide attempt.. his records reveal that this is his third suicide attempt in the past two years.. he is conscious, but does not respond to verbal commands for treatment.. which assessment finding should prompt the nurse to prepare the client for gastric lavage RATIONALE bc the client is unable to follow instructions, emetic therapy would be very difficult to implement and gastric lavage would be necessary QUES: a 72 year old female client is admitted to the psychiatric unit with a diagnosis of major depression.. which statement by the client should be of greatest concern to the nurse and require further assessment QUES: which diet selection by a client who is depressed and taking the MAOI tranylcypromine sulfate (Parnate) indicates to the nurse that the client understands the dietary restrictions imposed by this medication regimen QUES: 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 clients 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 clients history upon admission to the hospital QUES: a 65 year old female client complains to the nurse that recently she has been hearing voices.. what question should the nurse ask this client first QUES: on admission to a residential care facility, an elderly female client tells the nurse that she enjoys cooking, quilting, and watching television.. twenty four hours after admission, the nurse notes that the client is withdrawn and isolated.. it is best for the nurse to encourage this client to become involved in which activity RATIONALE peer interaction in a group activity will help to prevent social isolation and withdrawal QUES: 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 nurse to provide QUES: the nurse suspects child abuse when assessing a 3 year old boy and noticing several small, round burns on his legs and trunk that might be the result of cigarette burns.. which parental behavior provides the greatest validation for such suspicions QUES: a male adolescent is admitted with bipolar disorder after being released from jail for assault with a deadly weapon.. when the nurse asks the teen to identify his reason for the assault, he replies "bc he made me mad!".. which goal is best for the nurse to include in the clients plan of care. QUES: the nurse should include which interventions in the plan of care for a severely depressed client with neurovegetative symptoms QUES: the psychiatric nursing client may be an individual, family, group, organization, or community: QUES: the charge nurse is collaborating with the nursing staff about the plan of care for a client who is very depressed.. what is the most important intervention to implement during the first 48 hours after the clients admission to the unit QUES: at the first meeting of a group of older adults at a day care center for the elderly, the nurse 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 QUES: over a period of several weeks, one male participant of a socialization group at a community day care center for the elderly monopolizes most of the groups time and interrupts others when they are talking.. what is the best action for the nurse to take in this situation QUES: the nurse is taking a history for a female client who is requesting a routine female exam.. which assessment finding requires follow up QUES: The nurse is assessing the parents of a nuclear family who are attending a support group for parents of adolescents.. according to erickson, these parents who are adapting to middle adulthood should exhibit which characteristic QUES: a male client with schizophrenia tells the nurse that the voices he hears are saying "you must kill yourself".. to assist the client in coping with these thoughts, which response is best for the nurse to provide QUES: a woman arrives in the emergency center and tells the nurse she thinks she has been raped.. the client is sobbing and expresses disbelief that a rape could happen bc the man is her best friend.. after acknowledging the clients fear and anxiety, how should the nurse respond QUES: a woman admitted to the ED is bleeding profusely from a patch where hair was lost from her scalp.. she is accompanied by her husband who tells the nurse that his wife caught her hair on the railing and pulled it out when she fell down the stairs.. the husband is solicitous of his wife and quickly answers questions on her behalf.. he attempts to comfort his wife by saying to her "i am right here with you dear, nothing can keep us apart".. what is the priority nursing intervention QUES: while assessing a 70 year old male client, a nurse working in the outpatient clinic notices bruises on the clients chest.. the client admits that his daughter, who is is caregiver, becomes frustrated and sometimes hits him.. what is the priority outcome for the elderly client who sustained the abuse QUES: the nurse is assessing a client who is believed to have a borderline personality disorder.. which question is most important to include in this assessment QUES: a nurse is teaching a female client who is in a homosexual relationship about womens health.. which topic is the most important for the nurse to address QUES: a client who abuses alcohol says to the nurse, i am glad i went in for treatment.. now my problems with alcohol are all behind me.. which response is best for the nurse to provide QUES: a male client who is on the liver transplant list is called to the unit for a possible transplant.. when learning that the donor organ is no longer available, the client slams doors and shouts vulgarities about his situation.. what action should the nurse implement first QUES: a client is told that her infant will be stillborn.. what is the most important action for the nurse to implement after the birth QUES: a client who has a miscarriage at 10 weeks gestation tells the nurse that she already purchased some baby things and picked out a name.. after the surgical dilation and curettage, the client wants to go home as soon as possible.. based on the clients statements, which action should the nurse implement QUES: which nursing intervention should the nurse implement with parents who experience a fetal demise and express the wish not to see the baby QUES: a client actively involved in substance addiction therapy frequently relapses into benzodiazepines and alcohol use.. the client tells the nurse, i don't think i will ever be able to kick this habit.. how should the nurse respond QUES: a client who is admitted with the chief complaint of feeling depressed tells the nurse, i want to feel normal agiain.. how should the nurse respond QUES: the nurse is planning the care for a client based on the psychoanalytical model.. which intervention should the nurse include QUES: a female client responds to the nurse with negative comments and antagonistic behavior.. the nurse tells the client that she is unconsciously casting the nurse in the role of the clients mother.. the nurses feedback is based on which model of therapy QUES: which client should the nurse identify as the highest risk for the onset of stress related problems QUES: the client with depression asks the nurse, "what are neurotransmitters? my doctor thinks my problem may lie with the neurotransmitters in my brain".. what information should the nurse use to support an explanation of neurotransmitters QUES: a client is scheduled to complete a positron emission tomography (PET) scan.. the client asks the nurse to explain the reason the test was prescribed.. how should the nurse respond QUES: a client with panic disorder tells the nurse, "this illness is awful, I'm frightened that i will always be this way and that theres no hope for me".. what is the best information for the nurse to provide QUES: a female client who is admitted for treatment of uncontrolled DM is withdrawn and tearful.. she complains she has gained excessive weight bc she hates her diet, hates taking insulin, and just wants to be normal again.. what therapeutic action should the nurse take QUES: which action is most important for the nurse to implement during the initial interview for a client who is admitted to the mental health unit QUES: when assessing a clients emotional intelligence, which client capabilities should the nurse focus the interview on with a client diagnosed with a chronic mental illness QUES: a female client with severe depression is given information about risks, benefits, alternatives, and expected outcomes of ECT and signs the informed consent for treatment.. after the clients family leaves, the client tells the nurse, i signed the papers bc my husband told me i will be deported if my depression is not cured.. what information should the nurse report to the HCP QUES: a male client tells the nurse that he plans to kill his spouse and her lover as soon as he is released from the hospital.. what action should the nurse implement QUES: a male client is brought to the emergency department by a police officer, who reports the client was disturbing the peace by running naked in the street, striking out at others, and smashing care windows.. which behaviors should the client demonstrate to determine if he should be evaluated for involuntary commitment QUES: what action should the nurse take when a client who is psychotic proposes goals that are both unrealistic and undesirable QUES: a client is pacing in the hall near the nurses station and swearing loudly.. what response is best for the nurse to provide QUES: a client is responding to auditory hallucinations and shakes a fist at a nurse and says "back off witch!".. the nurse follows the client into the day room.. what action should the nurse implement QUES: a male client with severe orthopedic injuries following a motor vehicle collision is irritable, angry, and belittles the nurses.. while a nurse is changing the dressing over a laceration, the client screams "don't touch me! your so stupid that you'll make it worse!".. which intervention is best for the nurse to implement QUES: a 35 year old married woman works full time in a factory and has been absent from work for three days at a time on several occasions.. each time she returns to work, she wears dark glasses to cover facial bruising.. her supervisor refers her to the occupational health nurse.. what assessment question is most important for the nurse to initially use QUES: a female client presents to the emergency center with confusion, emotional numbness, and expresses to the nurse a feeling of disbelief that she was raped.. the nurse determines the client is in the acute phase of rape trauma syndrome.. what action should the nurse implement first QUES: which client outcome indicates improvement for a client who is admitted with auditory hallucinations QUES: the nurse is caring for an adult male client with catatonic schizophrenia who is mute and motionless.. what is the priority nursing diagnosis Ques: a client with a history of alcoholism with a compound fracture of the femur after falling down the previous night.. what additional assessment should be the priority focus for the nurse QUES: a client who is intoxicated is admitted for alcohol and multiple substance detoxification.. the nurse determines that the client is becoming increasingly anxious, agitated, and diaphoretic.. the client is also experiencing sensory perceptual disturbances and a clouded sensorium.. what is the priority nursing intervention for this client at this time? QUES: a female client comes to an outpatient therapy appointment intoxicated.. the spouse tells the nurse, "there wasn't anything i could do to stop her drinking this morning".. what intervention should the nurse take at this time QUES: which client statement should the nurse identify as most typical of a client with mania QUES: what nursing assessment is the priority focus for a client with major depression QUES: the nurse is caring for a client who received the first time ECT a half hour ago.. which action should the nurse implement first QUES: a client with substance abuse is admitted to the mental health unit.. which action should be implemented by the nurse, and not delegated to a UAP QUES: which action should the nurse implement first for a client experiencing alcohol withdrawal QUES: the nurse is caring for a client who was admitted for alcohol detoxification 2 days ago.. which finding is most critical for the nurse to report to the HCP QUES: during a one to one interaction, a male client describes the sadness he experienced when his mother died.. suddenly, the nurse begins to think about her grandmothers death.. as a result, the nurse asked the client to describe his thoughts when he learned of his own mothers illness.. what is the nurse doing QUES: the community health nurse facilitates a substance abuse prevention group for a homeless population.. which statement demonstrates that a client has a realistic understanding of the recovery process? QUES: a female client with bipolar disorder, manic phase, is planning weekend activities with the other clients on the unit.. the client interrupts the group, insists that they change their plans to a disco party, and begins to curse loudly when the group refuses to change the plans.. which intervention should the nurse implement QUES: which action should the nurse implement during the termination phase of the nurse client relationship? QUES: which statement made by an adolescent in group therapy should the nurse identify as a priority in planning care? QUES: the nurse is caring for a female client who is admitted for depression with the nursing diagnosis, self esteem, chronic low.. which client response indicates to the nurse that the client has improved self esteem QUES: during an inpatient therapy group session, a client tells the members that he hears voices that say his doctor is going to poison him.. he continues " i look around to see who's talking to me, and i can't see anybody".. another client replies "i used to hear voices, too.. i found out they were my imagination.. the voices you hear aren't real either".. which phenomenon, common to groups, is exemplified in this interchange QUES: an adolescent who attempted suicide with drug OD arrives in the ED with an empty 30 tab bottle of acetaminophen.. which action should the nurse implement QUES: a client on the mental health unit reports concerns about weight gain as a result of taking divalproex (Depakote) and requests assistance to fill out a menu.. the nurse should initiate a referral to which health care team QUES: during the admission of a male client to the mental health unit, the client tells the nurse that he had a panic attack today and ran out of the physicians office.. which question is most important for the nurse to ask the client QUES: the daughter of a female client with stage 1 alzehimers disease asks the nurse what changes should she expect to demonstrate in this stage.. what finding should the nurse tell the daughter is common? 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