PSY 55 | 3 HESI MENTAL HEALTH RN PSYCH 55 QUESTIONS and ANSWERS. Best Revision Paper Before Exams.

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HESI MENTAL HEALTH RN 55 QUESTIONS 1. A client with paranoia is admitted to the mental health unit and immediately goes to the corner of the room and sits quietly without communicating. In approachin... g the client, what intervention should the nurse implement first? • Explain the nurse's role to the client. 2. Client treated with lithium for bipolar develops diarrhea, vomiting and drowsiness, what action should the nurse do • Notify HCP of the symptoms prior to the next admin of the drug 3. A mental health worker (MHW) is caring for a client with escalating aggressive behavior, which action by the MHW warrants immediate intervention by the nurse? • Is attempting to physically restrain the client. 4. A woman who is bipolar is wearing low cut blouse, and skirt with no underwear, what does nurse do? • Walk her to room and help her pick out something more appropriate 5. An older man who recently got divorced and is 2 years sober, and an alcoholic loves God. He loves kids also. What should nurse ask at his initial interaction? • What is your biggest concern? 6. A woman who is diagnosed with breast cancer becomes dependent and asks family members if they can do ADL's that she is fully capable of doing. What is the reason for this behavior? • Its expected; regression is a natural start for recovery 7. Patient having to get treated for benzo diazepam and methadone overdose. What do you use? • Narcan 8. Patient watching TV starts talking loud to himself. The nurse comes in and can't distract him so turns down the TV. What should the nurse do then? • Move client to quieter room 9. In group therapy the charge nurse notices a client increasing to severe levels of anxiety. What should the nurse do? • Talk in a calm, approaching manner 10. A chronic depressed older man refuses to leave his room. His family moved away to a further location so they're not able to visit him as much. What approach should the nurse take with this man? • May I lay with you for a little? 11. Patient who is really depressed and won't talk or communicate, later is energetic and talkative. What should the nurse do? • Closely monitor the patient (could be suicidal) 12. Patient who had generalized anxiety disorder on Xanax long-term. What is the outcome? • Importance of not quickly stopping the drug 13. A mother has a 9-month-old baby with mental issues and growth issues. The mother comes in and says she's depressed because she’ll never have a normal baby. What should the nurse say? • Have you had any thoughts of harming your baby or yourself? 14. Lithium level 1.5. What do you tell the client who had a recent suicide attempt after seeing him become very anxious after hearing his Lithium levels? • drink 2-3L of water in 24 hours 15. Woman comes into ED having been raped by her date. What should the nurse document? • document she stated "I was raped by my date" 16. Which patient would require CAGE assessment? • Alcohol patient, cut down, annoyed, guilty, eye opener 17. A nurse is changing a dressing on a bipolar patient's stomach from self- inflicting knife wound. What is the nurse's best approach? • showing no signs of being judgmental 18. Woman is at a meeting with you, what is important for the nurse to document after hearing her issues in the relationship • get spouses statement as well 19. A patient in a corner with paranoid symptoms, staring and watching you. They refused to communicate with you. What do you do? • ask simple questions 20. A patient states "I can't get my thoughts together I should really sell my car. It’s not in here. Let's buy a car. What is the patient experiencing? • Tangential thinking 21. A depressed adolescent becomes sarcastic and irritate when you start to ask him questions. What does the nurse do? • Ask him to play cards 22. A patient who has been on an antidepressant for 2 weeks. What should you watch for? • suicidal attempts 23. A patient won't take oral meds that is going through alcohol withdrawal. The nurse starts giving saline lock per alcohol protocol and thiamine. What do you tell them that it will help with recovery? • Thiamine will replenish alcohol effects on the body (something to do with iron) 24. A male patient got divorced a year ago, lost his job, and recently suffered from a break up. What is his reason for his recent depression? • feelings of loss 25. A patient is being admitted for drug overdose. She says the reason she is using drugs is because of a recent breakup of an intimate relationship? what does the nurse do first • ask the patient if they feel as if they have a plan of suicide 26. A bipolar patient has stopped taking an antipsychotic. What other medication should the nurse expect to be D/C • benztropine (Congentin) 27. What should you recommend to a patient saying she can't get any sleep recently after receiving news she has breast cancer. What medication should you recommend? • Ativan 28. A patient has possessions she doesn't trust anyone to hold because she thinks they will steal them. How does the nurse establish trust? • make sure to talk short comments every now and then to her 29. A male adult comes to the mental health clinic and walks back and forth in front of the office door but does not enter the office. He then walks around a chair that is in the hallway several times before sitting down in the chair. What action should the nurse take? • first observe the client in the chair 30. A female client engages in repeated checks of door and window locks. Behavior that prevents her from arriving on time and interferes with her ability to function efectively. What action should the nurse take? • plan a list of activities to be carried out daily. 31. A male client with schizophrenia is admitted to the mental health unit after abruptly stopping his prescription for ziprasidone (Geodon) one month ago. Which question is most important for the nurse to ask the client? • Do you hear voices. 32. Which client statement suggests to the nurse that the client is using the defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit? • I am here because the police thought I was doing something wrong 33. A female client on a psychiatric unit is sweating profusely while she vigorously does push-ups and then runs the length of the corridor several times before crashing into the furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbances, the client shouts," I am the boss here. I do what I want." Which nursing problem best supports these observations? • Risk for other related violence related to disruptive 34. What is the most important goal for a client diagnosed with major depression who has been receiving an antidepressant medication for two weeks? • not attempt to commit suicide 35. Alcohol-Pancreatitis health assessment of history of alcohol dependency WHAT ELSE WOULD BE A CONCERN? • pancreatitis 36. Anorexia Nervosa-syncope Syncope is a clinical feature of? • Abuse-BAL- 37. Admission A female client with a history of drinking who was admitted 8 hours ago after receiving treatment for minor abrasions occurred from a fall at home. The nurse determines the client's blood alcohol level (BAL) was not analyzed on administration, What action should the nurse take? • Blood alcohol level- ask the client about alcohol quantity, frequency, and time of the last drink. 38. IPV- difficulty leaving victim of intimate partner violence what 3 things should you do? • establish a code with family and friends to signify violence • plan an escape route to use if the abuser blocks main exit • have a bag ready that has extra clothes for self and children 39. Anger Management • Give the client permission to be angry 40. Antisocial- interrupting 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? • Escort the client to a quieter place. 41. Borderline personality disorder self-inflicted lacerations on abdomen • perform the dressing change in a non-judgmental manner 42. Conversion disorder patient complains of blindness • Conversion disorder characterized by transferring a mental conflict into a physical symptom for which there is no organic cause. Ex: blindness, paralysis, seizures, deafness, and pseudocyesis(false pregnancy). 43. Countertransference occurs • when a mental health care professional redirects his or her feelings toward a client or becomes emotionally entangled with a client counter transference. 44. After returning to work after a weekend off the nurse gets report that a depressed client has been in bed all weekend. What should the nurse to first? • Assist the client out of bed and involve in activity. 45. A client with dementia uses the defense mechanism of confabulation. What is the reasoning? • To decrease anxiety. 46. A husband states to the nurse that his wife is not sleeping, buying impulsively, taking last minute trips, and has lost 22 pounds one month. What is an appropriate nursing dx? • Disturbed thought process. 47. 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? • ask to summarize-others need time also Borderline-interaction • Self-critical demanding, whiney, manipulative, argumentative and can be verbally abusive suicidal gestures. [Show More]

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