HESI RN MENTAL HEALTH 2018 V2

1. A client with depression remains in bed most of the day, declines activities and refuses meals. Which nursing problem has the greatest priority for this client? a. Loss of interest in diversional activity. b. Social isolation c. Refusal to address nutritional needs d. Low self-esteem. 2. The nurse is preparing medications for a client with bipolar disorder and notices that the antipsychotic medication was discontinued several days ago. Which medication should also be discontinued? a. Lithium (lithotabs ) b. Benztropine (Cogentin) c. Alprazolam (Xanax) d. Magnesium (milk of magnesia) 3. A female client request that her husband be allowed to stay in the room during the admission assessment. While interviewing the client, the nurse notes a discrepancy between the client’s verbal and nonverbal communication. What action should the nurse take? a. Pay close attention and document the nonverbal messages b. Ask the client’s husband to interpret the discrepancy c. Ignore the nonverbal behavior and focus on the client’s verbal messages. d. Integrate the verbal and nonverbal messages and interpret them as one. 4. A male client approaches the nurse with an angry expression on his face and raises his voice, saying, “My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out!” the nurse recognizes that the client is using which defense mechanism? a. Denial b. Projection c. Rationalization d. Splitting 5. A male client with bipolar disorder who began taking lithium carbonate five days ago is complaining of excessive thirst, and the nurse finds him attempting to drink water from the bathroom sink faucet. Which intervention should the nurse implement? a. Report the client’s serum lithium level to the healthcare provider b. Encourage the client to suck on hard candy to relieve the symptoms c. No actions is needed since polydipsia is a common side effect d. Tell the client that drinking from the faucet is not allowed 6. The nurse is teaching a client about the initiation of a prescribed abstinence therapy using disulfiram (Antabuse). What information should the client acknowledge understanding? a. Completely abstain from heroin or cocaine use b. Remain alcohol free from 12 hours prior to the first dose c. Attend monthly meetings of alcoholics anonymous d. Admit to others that he is a substance abuser 7. 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 a. Have you lost interest in the things that you used to enjoy? b. Is your ability to think or concentrate decreased? c. How many continuous hours do you sleep at night d. Do you hear sounds or voices that others do not hear? 8. During an annual physical by the occupational nurse working in a corporate clinic, a male employee tells the nurse that his high-stress job is causing trouble in his personal life. He further explains the he often gets so angry while driving to and from work that he has considered “getting even” with other drivers, how should the nurse respond? a. “anger is contagious and could result in major confrontation” b. “Try not to let your anger cause you to act impulsively” c. “expressing your anger to a stranger could result in an unsafe” d. It sound as if there are many situations that make you feel angry” 9. A client who has agoraphobia (a fear of crowds) is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care? a. Encourage substitution of positive thoughts for negative ones b. Establish trust by providing a calm, safe environment c. Progressively expose the client to larger crowds d. Encourage deep breathing when anxiety escalates in a crowd 10. A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone (Risperdal). When the client walks to the nurse’s station in a literally contracted position, he states that something has made his body confort into a monster. What action should the nurse take? a) Medicate the client with the prescribed antipsychotic thioridazine (mellaril) b) Offer the client a prescribed physical therapy hot pack for muscle spasms. c) Direct client to occupational therapy to distract him from somatic complaints. d) Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia.