HESI MENTAL HEALTH NCLEX-RN,Q&A WITH RATIONALE,100% CORRECT

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1. The nurse reviews the laboratory findings for a client's urine drug screen that is positive for cocaine. Which client behavior should be expected during cocaine withdrawal? 2. A middle-aged adul... t was discharged from a treatment center 6 weeks ago following treatment for suicide ideation and alcohol abuse. In a follow-up visit to the mental health clinic, the client complains of lethargy, apathy, irritability, and anxiety. Which question is most important for the nurse to ask? 3. A 25-year-old client has been particularly restless, and the nurse finds the client trying to leave the psychiatric unit. The client tells the nurse, "Please let me go! I must leave because the secret police are after me." Which response is best for the nurse to make? 4. A client who is being treated with lithium carbonate for manic depression begins to develop diarrhea, vomiting, and drowsiness. Which action should the nurse take? 5. A nurse working in the emergency department of a children's hospital admits a child whose injuries could have been the result of abuse. Which statement most accurately describes the nurse's responsibility in cases of suspected child abuse? 6. On admission, a highly anxious client is described as delusional. Delusions are most likely to occur with which disorders? 7. The nurse is planning to initiate a socialization group for older residents of a long-term facility. Which information would be most useful to the nurse when planning activities for the group? 8. The nurse is assessing a young client admitted to the psychiatric unit for acute depression related to a recent divorce. Which statement is most indicative of a client suffering from depression? 9. While in group therapy, a client who is diagnosed with posttraumatic stress disorder (PTSD) is processing an experience from the war in Iraq when another client tips over a chair. What action should the nurse take when the client with PTSD falls to the floor in a fetal position? 10. A middle-aged client tells the clinic nurse, "I'm again starting to feel overwhelmed and anxious with all my responsibilities. I don't know what to do." Which is the best response for the nurse to make? 11. During a home visit, a client with schizophrenia reports hearing voices that tell the client to walk in the middle of the street. The nurse records several statements made by the client. Based on which statement should the nurse determine that the client needs hospitalization? 12. A 27-year-old client is admitted to the psychiatric hospital with a diagnosis of bipolar disorder, manic phase. The client is demanding and active. Which intervention should the nurse include in this client's plan of care? 13. The nurse is caring for a client who is taking valproic acid. Which laboratory finding is most important to include in this client's record? 14. A client on the psychiatric unit seeks out a particular nurse and imitates her mannerisms. Which defense mechanism does the nurse recognize in this client? 15. A client begins taking an atypical antipsychotic medication. The nurse must provide informed consent and education about common medication side effects. Which client education will be most important? 16. The nurse admits a client with depression to the mental health unit. The client reports difficulty concentrating, has lost 10 pounds in 2 weeks, and is sleeping 12 hours a day. Which outcome is most important for the client to meet by discharge? 18. A client who has been admitted to the psychiatric unit tells the nurse, "My problems are so bad. No one can help me." Which response would be best for the nurse to make? 19. Physical examination of a 6-year-old boy reveals several bite marks in various locations on his body. X-ray examination reveals healed fractures of the ribs. The mother tells the nurse that her child is always having accidents. Which initial response by the nurse would be most appropriate? 20. A 45-year-old male client tells the nurse that he used to believe that he was Jesus Christ, but now he knows that he is not. Which response is best for the nurse to make? 21. Which topics should the nurse include in an education program for clients with schizophrenia and their families? (Select all that apply.) 22. An 8-year-old child is seen in the clinic with a green vaginal discharge. Which action is most important for the nurse to implement? 23. A client is admitted with a diagnosis of depression. Which of the following characteristics is most indicative of depression? 24. A client who was admitted two days earlier to a drug rehabilitation unit tells the nurse, "I'm going to do what you people tell me to do so I can get out of here and get a job." What is the most accurate interpretation of this client's statement? 25. When planning care for the client undergoing electroconvulsive therapy (ECT), which equipment should the nurse make available? (Select all that apply.) 26. A 35-year-old client admitted to the psychiatric unit of an acute care hospital tells the nurse that someone is trying to poison her. The client's delusions are most likely related to which factor? 27. A client in the critical care unit who has been oriented suddenly becomes disoriented and fearful. Assessment of vital signs and other physical parameters reveals no significant changes, and the nurse formulates the diagnosis of confusion related to ICU psychosis. Which intervention is best to implement based on this client's behavior? 28. An individual with a known history of alcohol abuse is admitted for emergency surgery following a motor vehicle collision. The nurse includes in the client's plan of care, "Observe for signs of delirium tremens." Which early signs indicate that the client is beginning to have delirium tremens? 29. A 38-year-old client is admitted with a diagnosis of paranoid schizophrenia. When the lunch tray is brought to the room, the client refuses to eat and tells the nurse, "I know you are trying to poison me with that food." Which response by the nurse is the most therapeutic? 30. A client who has been hospitalized for 2 weeks for paranoia reports continuously to the staff that someone is trying to steal his clothing. What is the correct action for the nurse to take based on the client's complaints? 31. A child is brought to the emergency department with a broken arm. Because of other injuries, the nurse suspects that the child may be a victim of abuse. When the nurse tries to give the child an injection, the child's mother becomes very loud and shouts, "I won't leave my son! Don't you touch him! You'll hurt my child!" What is the best interpretation of the mother's statements? 32. Over a period of several weeks, one participant of a socialization group at a community daycare center for older adults monopolizes most of the group's time and interrupts others when they are talking. What is the best action for the nurse to take in this situation? 33. An adult client who lives in a residential facility is mentally retarded and has a history of bipolar disorder. During the past week, the client has refused to wear clothes and frequently exposes his/her body to other residents. Which intervention should the nurse implement? 34. A client believes that his health care provider is an FBI agent and that his apartment is a site for slave trading. The client believes that the FBI has cameras in the apartment, so it is not safe to return there. Based on these symptoms, which class of medication is most likely to be prescribed for this client? 35. Which behavior indicates to the nurse that a client with paranoid ideas is improving? 36. The nurse develops a plan of care for a client with symptoms of paranoia and psychosis. The priority nursing diagnosis is impaired social interactions related to inability to trust. Which intervention is most important for the nurse to implement? 37. The nurse cares for an adolescent with a history of violence who now exhibits signs of sublimation. Which behavior by the adolescent best represents sublimation? 38. At the first meeting of a group at a daycare center for older adults, the nurse asks one of the members what kinds of things the client would like to do with the group. The older adult shrugs and says, "You tell me. You're the leader." What would be the best response for the nurse to make? 39. On admission, a depressed client tells the nurse, "I can't eat because my tongue is rubber." Which is the best action for the nurse to implement? 40. A client on the psychiatric unit, diagnosed with bipolar disorder, becomes loud and shouts at one of the nurses, "You fat tub of lard, get something done around here!" What is the best initial action for the nurse to take? 41. Clients are preparing to leave the mental health unit for an outdoor smoke break. A client on constant observation cannot leave and becomes agitated and demands to smoke a cigarette. Which action should the nurse take first? 42. What instructions should the nurse include in the discharge teaching plan of a client who has recently been prescribed oxazepam? (Select all that apply.) 43. The nurse notes multiple burns on the arms and chest of a 2-year-old Vietnamese child who is being treated for dehydration. When questioned, the child's father states that he treated the child's vomiting with the cultural practice termed coining, which resulted in burned areas. Which expected outcome statement has the highest priority? 44. A woman brings her 48-year-old husband to the outpatient psychiatric unit and tells the nurse that he is being treated for dissociative disorder. Which data are consistent with this diagnosis? (Select all that apply.) 45. A 33-year-old client is admitted to a psychiatric facility with a medical diagnosis of major depression. When the nurse is assigning the client to a room, which roommate is best for this client? 46. A schizophrenic client who is taking fluphenazine decanoate is being discharged in the morning. A repeat dose of medication is scheduled for 20 days after discharge. The client tells the nurse about a planned vacation and will return in 18 days. Which statement by the client indicates to the nurse a need for health teaching? 47. A 25-year-old client has suffered extensive burns and is crying during dressing change treatment. The client tells the nurse, "Please let me die. Why are you all torturing me like this? I just want to die." Which response by the nurse is best? Select an option, then click Submit. 48. A client who recently retired is admitted to the psychiatric inpatient unit with a diagnosis of major depression. The initial nursing care plan includes the goal "Assist client to express feelings of guilt." What is true about the goal statement referring to the client's depression? 49. A 22-year-old client is admitted to the psychiatric unit from the medical unit following a suicide attempt with an overdose of diazepam. When developing the nursing care plan for this client, which intervention would be most important for the nurse to include? 50. A client mumbles out loud whether anyone is talking to her or not, and the client also mumbles in group when others are talking. The nurse determines that the client is experiencing hallucinations. Which intervention should the nurse implement? [Show More]

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