HESI PN MENTAL HEALTH PROCTORED EXAM

HESI PN MENTAL HEALTH PROCTORED EXAM

VERSION 3

• A charge nurse is discussing mental status examinations with a newly licensed nurse.

Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? (select all that apply.)

• “To assess cognitive ability, I should ask the client to count backward by sevens.”

counting backward by 7s is an appropriate technique to assess a client’s cognitive ability.

• “To assess affect, I should observe the client’s facial expression.” Observing a client’s

facial expression is appropriate when assessing affect.

• “To assess language ability, I should instruct the client to write a sentence.” Writing a

sentence is an indication of language ability.

• A nurse is planning care for a client who has a mental health disorder. Which of the

following actions should the nurse include as a psychobiological intervention?

• Monitor the client for adverse effects of medications. Monitoring for adverse effects

of medications is an example of a psychobiological intervention.

• A nurse in an outpatient mental health clinic is preparing to conduct an initial client

interview. When conducting the interview, which of the following actions should the nurse identify as the priority?

• Identify the client’s perception of her mental health status. assessment is the priority

action when using the nursing process approach to client care. identifying the client’s perception of her mental health status provides important information about the client’s psychosocial history.

• A nurse is told during change‐of‐shift report that a client is stuporous. When assessing the

client, which of the following findings should the nurse expect?

• The client arouses briefly in response to a sternal rub. A client who is stuporous

requires vigorous or painful stimuli to elicit a response.

• A nurse is planning a peer group discussion about the Diagnostic and Statistical Manual

of Mental Disorders, 5th edition (DsM‐5). Which of the following information is appropriate to include in the discussion? (select all that apply.)

• the DSM‐5 establishes diagnostic criteria for individual mental health disorders.
• the DSM‐5 assists nurses in planning care for client’s who have mental health

disorders.

• the DSM‐5 indicates expected assessment findings of mental health disorders.
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Chapter 2

• A nurse in an emergency mental health facility is caring for a group of clients. the nurse

should identify that which of the following clients requires a temporary emergency admission?

• A client who has borderline personality disorder and assaulted a homeless man with

a metal rod. A client who is a current danger to self or others is a candidate for a temporary emergency admission.

• A nurse decides to put a client who has a psychotic disorder in seclusion overnight

because the unit is very short‐staffed, and the client frequently fights with other clients.the nurse’s actions are an example of which of the following torts?

• False imprisonment. A civil wrong that violates a client’s civil rights is a tort. in this

case, it is false imprisonment, which is the confining of a client to a specific area, such as a seclusion room, if the reason for such confinement is for the convenience of staff.

• A client tells a nurse, “don’t tell anyone, but i hid a sharp knife under my mattress in

order to protect myself from my roommate, who is always yelling at me and threatening me.” Which of the following actions should the nurse take?

• Tell the client that this must be reported to the health care team because it

concerns the health and safety of the client and others. The information presented by the client is a serious safety issue that the nurse must report to the health care team. using the ethical principle of veracity, the student tells the client truthfully what must be done regarding the issue.

• A nurse is caring for a client who is in mechanical restraints. Which of the following

statements should the nurse include in the documentation? (select all that apply.)

• “Client was offered 8 oz of water every hr.” how much water was offered and how

often it was offered is objective data that the nurse should document when caring for a client in mechanical restraints.

• “Client shouted obscenities at assistive personnel.” A description of the client’s verbal

communication is objective data that the nurse should document when caring for a client in mechanical restraints.

• “Client received chlorpromazine 15 mg by mouth at 1000.” The dosage and time of

medication administration is objective data that the nurse should document when caring for a client in mechanical restraints

• A nurse hears a newly licensed nurse discussing a client’s hallucinations in the hallway

with another nurse. Which of the following actions should the nurse take first?

• tell the nurse to stop discussing the behavior. The greatest risk to this client is an

invasion of privacy through the sharing of confidential information in a public place. the first action the nurse should take is to tell the newly licensed nurse to stop discussing the client’s hallucinations in a public location.

Chapter 3

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• A charge nurse is conducting a class on therapeutic communication to a group of

newly licensed nurses. Which of the following aspects of communication should the nurse identify as a component of verbal communication?

• intonation. The nurse should identify intonation as a component of verbal

communication. intonation is the tone of one’s voice and can communicate a variety of feelings.

• A nurse in an acute mental health facility is communicating with a client. the client

states, “I can’t sleep. I stay up all night.” the nurse responds, “You are having difficulty sleeping?” Which of the following therapeutic communication techniques is the nurse demonstrating?

• Restating. Restating allows the nurse to repeat the main idea expressed.

• A nurse is communicating with a client who was just admitted for treatment of a

substance use disorder. Which of the following communication techniques should the nurse identify as a barrier to therapeutic communication?

• Offering advice. Offering advice to a client is a barrier to therapeutic

communication that the nurse should avoid using. advice tends to interfere with the client’s ability to make personal decisions and choices.

• A nurse caring for a client who has anorexia nervosa. Which of the following

examples demonstrates the nurse’s use of interpersonal communication?

• the nurse asks the client about her body image perception. The nurse’s one‐on‐one

communication with the client is an example of interpersonal communication.

• A nurse is caring for the parents of a child who has demonstrated recent changes in

behavior and mood. When the mother of the child asks the nurse for reassurance about her son’s condition, which of the following responses should the nurse make?

• “I understand you’re concerned. Let’s discuss what concerns you specifically.”

The therapeutic response reflects upon, and accepts, the parents’ feelings, and it allows them to clarify what they are feeling.

Chapter 4

• A nurse is caring for a client who smokes and has lung cancer. the client reports,

“I’m coughing because I have that cold that everyone has been getting.” The nurse should identify that the client is using which of the following defense mechanisms?

• denial. This is an example of denial, which is pretending the truth is not reality

to manage the anxiety of acknowledging what is real.

• A nurse is providing preoperative teaching for a client who was just informed that 3 / 4

she requires emergency surgery. the client, has a respiratory rate 30/min, and says, “this is difficult to comprehend. I feel shaky and nervous.” the nurse should identify that the client is experiencing which of the following levels of anxiety?

• Moderate anxiety decreases problem‐solving and may hamper the client’s

ability to understand information. Vital signs may increase somewhat, and the client is visibly anxious.

• A nurse is caring for a client who is experiencing moderate anxiety. Which of the

following actions should the nurse take when trying to give necessary information to the client? (Select all that apply.)

• Discuss prior use of coping mechanisms with the client. This assists the client in

identifying ways of effectively coping with the current stressor.

• Demonstrate a calm manner while using simple and clear directions. Providing

a calm presence assists the client in feeling secure and promotes relaxation. clients experiencing moderate levels of anxiety often bene t from the direction of others.

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Chapter 5

• A nurse is talking with a client who is at risk for suicide following the death of his

spouse. Which of the following statements should the nurse make?

• “Losing someone close to you must be very upsetting.” This statement is an

empathetic response that attempts to understand the client’s feelings.

• A charge nurse is discussing the characteristics of a nurse-client relationship with a newly

licensed nurse. Which of the following characteristics should the nurse include in the discussion? (Select all that apply.)

• It is goal-directed. A therapeutic nurse-client relationship is goal-directed.

• Behavioral change is encouraged. A therapeutic nurse-client relationship encourages

positive behavioral change.

• A termination date is established. A therapeutic nurse-client relationship has an

established termination date.

• A nurse is in the working phase of a therapeutic relationship with a client who has

methamphetamine use disorder. Which of the following actions indicates transference behavior?

• The client accuses the nurse of telling him what to do just like his ex-girlfriend. When

a client views the nurse as having characteristics of another person who has been significant to his personal life, such as his ex-girlfriend, this indicates transference.

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