HESI PN Mental Health Exam
VERSION 18
Toddlers have recently mastered walking and experience many falls and collisions. Because the bruises are in various stages of healing and are located over bony prominences, this likely indicates falling on several occasions. 1 / 4
A 9-month-old infant who reportedly nearly drowned after climbing into the tub and turning on the water The nurse should identify that, while a 9-month-old might have the ability to climb into the tub, it is unlikely that he could turn the water on. The nurse should suspect possible abuse because the reported cause of the accident seems inconsistent with the developmental abilities of most 9- month-old infants.A 6-year-old toddler who has a fracture of the tibia and fibula, which reportedly occurred while riding a bicycle Fractures can be caused by physical abuse, but this 6-year-old child is learning to ride a bicycle.This injury is consistent with having a fallen off of a bicycle.A 3-year-old toddler who has burns in a splash pattern over the face and chest, reportedly sustained when a tablecloth was pulled, spilling a teapot The history is consistent with the injury. Toddlers frequently help pull themselves up by pulling on objects that might be unstable. The splash of burns would occur from the head downward.
A nurse is caring for a client who has a new diagnosis of colon cancer. Shortly after the client receives the diagnosis, the nurse enters the client's room and the client begins yelling, "I have received terrible care here and no one cares about me." The nurse should recognize that the client is demonstrating which of the following defense mechanism
Denial The nurse should identify denial as the refusal to accept reality and to act as if a painful event, thought, or feeling does not exist.Displacement The nurse should identify displacement as the redirection of thoughts, feelings, and impulses from an object that causes to anxiety to a safer, more acceptable one. In this scenario, the client is redirecting his anxiety about the diagnosis to the staff that is providing care.Reaction formation 2 / 4
The nurse should identify reaction formation when the client exhibits a behavior or emotion that is the opposite of what the client actually feels.Projection The nurse should identify projection when the client attributes undesired impulses to another
A nurse receives a call on a crisis intervention hotline from a client. Which of the following statements should the nurse identify as an overt statement indicating the client's risk for suicide
"Everything will be better soon." The nurse should identify this client comment as a covert statement."Soon no one will have to worry about me." The nurse should identify this client comment as a covert statement."There's no point in living any longer." The nurse should identify this client comment as an overt statement about the client’s risk for suicide. The nurse should assess the client’s suicidal ideation further and implement interventions to promote her safety."I want to donate my organs to help others." The nurse should identify this client comment as a covert statement.
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A nurse is caring for a client who has depression and started taking paroxetine one week ago. The client states to the nurse, "My family would be better off without me." Which of the following responses should the nurse make?
"Why do you feel your family would be better off without you?" The nurse should avoid asking a "why" question, which blocks communication by promoting a defensive client reaction."Many people feel this way when they are depressed." This response exemplifies the nontherapeutic communication block of using a cliché. Telling the client that "many people feel this way" minimizes and takes the focus off of the client’s feelings."You sound upset. Are you thinking of hurting yourself?"
MY ANSWER
This response exemplifies the therapeutic communication technique of showing empathy.Telling the client, "You sound upset," focuses on the client’s feelings, which is a demonstration of therapeutic communication. In addition, the nurse addresses the possibility of suicidal ideation by asking the client directly whether or not she has an intent to harm herself."Your medication hasn't started working yet. Then you'll be feeling differently. " This response exemplifies the nontherapeutic communication block of giving false reassurance.While the nurse is correct that antidepressant medications often take up to 3 weeks to take effect, there is no guarantee that the client will feel better at that time.
A nurse is admitting a client following care in the emergency department for an intentional overdose of opioids. The client states, "I feel so alone. No one can help me." Which of the following responses by the nurse is therapeutic?
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