HESI RN Mental Health Exam

HESI RN Mental Health Exam

VERSION 4

• 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?

• 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 e²ectively. What action should the nurse take plan a list of activities to be carried out daily.

• 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.

• 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 action should the nurse take Ask client about alcohol quantity, frequency, and time of last drink

• 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

• 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

• Alcohol-Pancreatitis health assessment of history of alcohol dependency

WHAT ELSE WOULD BE A CONCERN pancreatitis

• Anorexia Nervosa-syncope Syncope is a clinical feature Abuse-BAL-
• 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 action should the nurse take Blood alcohol level- ask the client about alcohol quantity, frequency, and time of the last drink.

• IPV- difficulty leaving victim of intimate partner violence what 3 things 1 / 2

should you do 1. establish a code with family and friends to signify violence, 2. plan an escape route to use if the abuser blocks main exit, 3.have a bag ready that has extra clothes for self and children

• Anger Management Give the client permission to be angry
• 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? C. Escort the client to a quieter place.

• borderline personality disorder self-inflicted lacerations on abdomen

perform the dressing change in a non-judgemental manner *ask to summarize-others need time also Borderline-interaction 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?

• Do you frequently have temper tantrums? Self-critical demanding,

whiney, manipulative, argumentative and can be verbally abusive suicidal gestures. borderline personality disorder self-inflicted lacerations on abdomen perform the dressing change in a non -judge mental manner.

• Conversion disorder patient complains of blindness Conversion

disorder 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).

• 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.

• Part five
• 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.
• A client with dementia uses the defense mechanism of confabulation.

What is the reasoning?

• To decrease anxiety.
• 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?

HESI MENTAL HEALTH V3 2017 55 QUESTIONS

• Disturbed thought process.
• A nurse is explaining a fire drill routine to a group of clients. A client

becomes disruptive and continually interrupts the group. What is the nurse's best response?

• When you interrupt, I cannot explain what to do to the group.
• When performing a MSE on a client which assessment intervention
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