NGN HESI MENTAL HEALTH RN V1 -V3 TEST BANK

NGN HESI MENTAL HEALTH RN V1 -V3 TEST BANK

EXAM QUESTIONS & CORRECT DETAILED

ANSWERS GRADED A+

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 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 disturbance, the client shouts, "I am the boss here. I do what I want." Which nursing problem best supports these observations?

• Deficient diversional activity related to excess energy level.
• Risk for other related violence related to disruptive behavior.
• Risk for activity intolerance related to hyperactivity.
• Disturbed personal identity related to grandiosity.
• Risk for other related violence related to disruptive behavior.

A RN is preparing the physical environment to interview a new client for admission to the mental health unit. Which environmental setting facilitates the best outcome of the interview?

• Dim the lights in the room to help the patient feel calm.
• Sit within two feet of the client to enhance level of safety and security.
• Reduce the noise level in the room by turning off the television and radio.
• Position table between the client and the RN for extra personal space.
• Reduce the noise level in the room by turning off the television and radio.

An older homeless client visits the psychiatric clinic to obtain a prescription renewal for alprazolam (Xanax). During the health assessment, the client complains of chest pain. Which action should the RN take first?

• Refer the client to the cardiology unit.
• Obtain the client Blood pressure.
• Assess the client for substance abuse.

D.

• Determine if Xanax was taken recently.

The mother of an 8-month-old infant with profound mental and physical disabilities tells the RN how depressed she is because she realized that her child will never achieve normal growth and development milestones. How should the RN respond to the mother?

• Ask the mother if she has ever thought about harming herself or her child.
• Reassure the mother that her child will achieve some growth and development

milestones. 1 / 3

• Determine if the mother has other children who do not have developmental disabilities.
• Encourage the mother to write thoughts and feelings in journal.
• Ask the mother if she has ever thought about harming herself or her child.

Several clients with chronic mental illness and multiple substance abuse histories live in a group residential home and attend daycare mental health facility where group and individual therapies are provided. The RN finds the common bathroom at the facility with sputum on the walls, urine in the sink and on the floors, and the toilet stopped up with tissue, paper towels, and feces. What is the priority issue that the RN should address?

• Medication non-compliance.
• Number of bathroom facilities.

C.

• Acting out behaviors.
• Infection control.

A client with schizophrenia is admitted to the psychiatric care unit for aggressive behavior, auditory hallucinations, and potential for safe harm. The client has not been taking medications as prescribed and insists that the food has been poisoned and refuses to eat. What intervention should the RN implement?

• Assure the client that all food served in the hospital is safe to eat.
• Tell the client that irrational thinking is a symptom of schizophrenia.
• Obtain an order for a tube feeding for the client.
• Provide the client with food in unopened containers.
• Provide the client with food in unopened containers.

The RN is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? (SOA)

• Purchase a gun to use for protection.

B.

• Take a self-defense course that retaliates the abuser with injury.

D.E.

• Establish a code with family and friends to signify violence.
• Have a bag ready that has extra clothes for self and children.
• Plan an escape route to use if the abuser blocks the main exit.

The RN is admitting a male client who take lithium carbonate (Eskalith) twice a day. Which information should the RN report to the HCP immediately?

• Short term memory loss.
• Five pound weight gain 2 / 3

• Decreased affect.

D.

• Nausea and vomiting.

A male client who is admitted with delirium tremens is dehydrated and experiencing auditory hallucinations. He has a bruised, swollen tongue and is confused. In developing a plan of care, which action should the RN include to ensure the client is physiologically stable?

• Encourage oral fluids.

B.

• Keep the room dark.
• Apply ice to his tongue.
• Monitor vital signs.

A RN is teaching a client about initiation of a prescribed abstinence therapy using Disulfiram (Antabuse). What information should the client acknowledge understanding?

• Admit to others that he is a substance abuser.
• Remain alcohol free for 12 hours prior to first dose.
• Attend monthly meetings of alcoholics anonymous.
• Completely sustain from heroin or cocaine use.
• Remain alcohol free for 12 hours prior to first dose.

The RN is working with a male client at a community mental health center when the client reports hearing voices that tell him to get a knife from the kitchen and hurt himself. What intervention is most important for the RN to implement?

• Don't allow the client to go into the kitchen until the hallucination has subsided.
• Report the behavior to the client's case workers so that the family can be notified.

C.

• Document the behavior in the client's record and notify the HCP.
• Assign the UAP to remain with the client at all times.

A homeless client who reports feeling sad and depressed tells the mental health nurse that in the past

• days she has only had 4 hours of sleep. Which action is most important for the RN to implement

within the first 24 hours after treatment is initiated?A.

• Ensure client attend groups addressing coping skills for dealing with depression.
• Begin planning for the clients discharge.
• Encourage verbalization of feelings.
• Allow the client to rest and sleep.

Which client statement suggests the RN that the client is using a defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit?

• At least I hit the wall instead of hitting the psychiatric aide.
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