HESI: Psych/Mental Health Nursing – Flashcards
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A 30-year-old sales manager tells the nurse, "I am thinking about a job change. I don't feel like I am living up to my potential." Which of Maslow's developmental stages is the sales manager attempting to achieve?
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Self-Actualization
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The nurse plans to help an 18-year-old female mentally retarded client ambulate the first postoperative day after an appendectomy. When the nurse tells the client it is time to get out of bed, the client becomes angry and tells the nurse, "Get out of here! I'll get up when I'm ready!" Which response is best for the nurse to make?
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I'll be back in 30 minutes to help you get out of bed and walk around the room.
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A 22-year-old male client is admitted to the emergency center following a suicide attempt. His records reveal that this is his third suicide attempt in the past two years. He is conscious, but does not respond to verbal commands for treatment. Which assessment finding should prompt the nurse to prepare the client for gastric lavage?
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He is unresponsive to instructions and is unable to cooperate with emetic therapy
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A male client is admitted to a mental health unit on Friday afternoon and is very upset on Sunday because he has not had the opportunity to talk with the healthcare provider. Which response is best for the nurse to provide this client?
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Let me call and leave a message for your healthcare provider.
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An elderly female client with advanced dementia is admitted to the hospital with a fractured hip. The client repeatedly tells the staff, "Take me home. I want my Mommy." Which response is best for the nurse to provide?
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Tell the client that the nurse is there and will help her.
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The nurse is assessing the parents of a nuclear family who are attending a support group for parents of adolescents. According to Erikson, these parents who are adapting to middle adulthood should exhibit which characteristic?
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Increased self-understanding.
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The nurse suspects child abuse when assessing a 3-year-old boy and noticing several small, round burns on his legs and trunk that might be the result of cigarette burns. Which parental behavior provides the greatest validation for such suspicions?
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The parents tell the nurse that the child was burned in a house fire which is incompatible with the nurse's observation of the type of burn
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A 25-year-old female client has been particularly restless and the nurse finds her trying to leave the psychiatric unit. She 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?
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Come with me to your room and I will sit with you.
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A 35-year-old male client on the psychiatric ward of a general hospital believes that someone is trying to poison him. The nurse understands that a client's delusions are most likely related to his
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low self-esteem
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Which ego-defense mechanisms are exhibited by a phobic client who refuses to leave her home?
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Symbolization.
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A young adult male client, diagnosed with paranoid schizophrenia, believes that world is trying poison him. What intervention should the nurse include in this client's plan of care?
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Ask one nurse to spend time with the client daily.
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A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care?
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Excessive CNS stimulation will be reduced.
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A 45-year-old female client is admitted to the psychiatric unit for evaluation. Her husband states that she has been reluctant to leave home for the last six months. The client has not gone to work for a month and has been terminated from her job. She has not left the house since that time. This client is displaying symptoms of what condition?
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Agoraphobia.
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The nurse should hold the next scheduled dose of a client's haloperidol (Haldol) based on which assessment finding(s)?
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Fever of 102° F.
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A nurse working on a mental health unit receives a community call from a person who is tearful and states, "I just feel so nervous all of the time. I don't know what to do about my problems. I haven't been able to sleep at night and have hardly eaten for the past 3 or 4 days." The nurse should initiate a referral based on which assessment?
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Moderate levels of anxiety.
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A 40-year-old male client diagnosed with schizophrenia and alcohol dependence has not had any visitors or phone calls since admission. He reports he has no family that cares about him and was living on the streets prior to this admission. According to Erikson's theory of psychosocial development, which stage is the client in at this time?
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Stagnation.
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On admission, a highly anxious client is described as delusional. The nurse understands that delusions are most likely to occur with which class of disorder?
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Psychotic
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A 65-year-old female client complains to the nurse that recently she has been hearing voices. What question should the nurse ask this client first?
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Are you ever alone when you hear the voices?
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A female client with depression attends group and states that she sometimes misses her medication appointments because she feels very anxious about riding the bus. Which statement is the nurse's best response?
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What are some ways that you can cope with your anxiety?
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An anxious client expressing a fear of people and open places is admitted to the psychiatric unit. What is the most effective way for the nurse to assist this client?
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Accompany her outside for an increasing amount of time each day.
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The nurse is planning discharge for a male client with schizophrenia. The client insists that he is returning to his apartment, although the healthcare provider informed him that he will be moving to a boarding home. What is the most important nursing diagnosis for discharge planning?
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Ineffective denial related to situational anxiety.
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A client is admitted with a diagnosis of depression. The nurse knows that which characteristic is most indicative of depression?
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A negative view of self and the future.
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The nurse is preparing to administer phenelzine sulfate (Nardil) to a client on the psychiatric unit. Which complaint related to administration of this drug should the nurse expect this client to make?
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My mouth feels like cotton.
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Within several days of hospitalization, a client is repeatedly washing the top of the same table. Which initial intervention is best for the nurse to implement to help the client cope with anxiety related to this behavior?
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Allow time for the ritualistic behavior, then redirect the client to other activities
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A client who has been admitted to the psychiatric unit tells the nurse, "My problems are so bad that no one can help me." Which response is best for the nurse to make?
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How can I help?
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The nurse is taking a history for a female client who is requesting a routine female exam. Which assessment finding requires follow-up?
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Black-out after one drink last night on a date
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A 45-year-old male client tells the nurse that he used to believe that he was Jesus Christ, but now he knows he is not. Which response is best for the nurse to make?
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Others have had similar thoughts when under stress.
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An 86-year-old female client with Alzheimer's disease is wandering the busy halls of the extended care facility and asks the nurse, "Where should I stand for the parade?" Which response is best for the nurse to provide?
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Let us go back to the activity room and see what is going on in there
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A 22-year-old male client is admitted to the emergency center following a suicide attempt. His records reveal that this is his third suicide attempt in the past two years. He is conscious, but does not respond to verbal commands for treatment. Which assessment finding should prompt the nurse to prepare the client for gastric lavage?
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He is unresponsive to instructions and is unable to cooperate with emetic therapy.
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The nurse is assessing a client's intelligence. Which factor should the nurse remember during this part of the mental status exam?
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Intelligence is influenced by social and cultural beliefs.
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A client on the psychiatric unit appears to imitate a certain nurse on the unit. The client seeks out this particular nurse and imitates her mannerisms. The nurse knows that the client is using which defense mechanism?
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Identification.
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A 38-year-old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her, she refuses to eat and tells the nurse, "I know you are trying to poison me with that food." Which response is most appropriate for the nurse to make?
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I'll leave your tray here. I am available if you need anything else.
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A nurse working in the emergency room of a children's hospital admits a child whose injuries could have resulted from abuse. Which statement most accurately describes the nurse's responsibility in cases of suspected child abuse?
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The nurse should report any case of suspected child abuse to the nurse in charge.
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A 35-year-old male client who has been hospitalized for two weeks for chronic paranoia continues to state that someone is trying to steal his clothing. Which action should the nurse implement?
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Encourage the client to actively participate in assigned activities on the unit.
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A male client is admitted to the mental health unit because he was feeling depressed about the loss of his wife and job. The client has a history of alcohol dependency and admits that he was drinking alcohol 12 hours ago. Vital signs are: temperature, 100° F, pulse 100, and BP 142/100. The nurse plans to give the client lorazepam (Ativan) based on which priority nursing diagnosis?
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Risk for injury related to alcohol detoxification.
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A female client refuses to take an oral hypoglycemic agent because she believes that the drug is being administered as part of an elaborate plan by the Mafia to harm her. Which nursing intervention is most important to include in this client's plan of care?
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Reassess client's mental status for thought processes and content.
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A client who is diagnosed with schizophrenia is admitted to the hospital. The nurse assesses the client's mental status. Which assessment finding is most characteristic of a client with schizophrenia?
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Flat affect
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A male client with mental illness and substance dependency tells the mental health nurse that he has started using illegal drugs again and wants to seek treatment. Since he has a dual diagnosis, which person is best for the nurse to refer this client to first?
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His case manager
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he nurse is planning care for a 32-year-old male client diagnosed with HIV infection who has a history of chronic depression. Recently, the client's viral load has begun to increase rather than decrease despite his adherence to the HIV drug regimen. What should the nurse do first while taking the client's history upon admission to the hospital?
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Ask the client if he takes St. John's Wort routinely.
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A client who is known to abuse drugs is admitted to the psychiatric unit. Which medication should the nurse anticipate administering to a client who is exhibiting benzodiazepine withdrawal symptoms?
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Chlordiazepoxide (Librium)
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An adult male client who was admitted to the mental health unit yesterday tells the nurse that microchips were planted in his head for military surveillance of his every move. Which response is best for the nurse to provide?
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Go to occupational therapy and start a project.
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A woman arrives in the Emergency Center and tells the nurse she thinks she has been raped. The client is sobbing and expresses disbelief that a rape could happen because the man is her best friend. After acknowledging the client's fear and anxiety, how should the nurse respond?
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"Rape is not limited to strangers and frequently occurs by someone who is known to the victim."
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The parents of a 14-year-old boy bring their son to the hospital. He is lethargic, but responsive. The mother states, "I think he took some of my pain pills." During initial assessment of the teenager, what information is most important for the nurse to obtain from the parents?
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If he might have taken any other drugs.
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A male adolescent is admitted with bipolar disorder after being released from jail for assault with a deadly weapon. When the nurse asks the teen to identify his reason for the assault, he replies, "Because he made me mad!" Which goal is best for the nurse to include in the client's plan of care? The client will
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control impulsive actions toward self and others
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Physical examination of a 6-year-old 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?
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Tell me more specifically about your child's accidents.
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A 27-year-old female client is admitted to the psychiatric hospital with a diagnosis of bipolar disorder, manic phase. She is demanding and active. Which intervention should the nurse include in this client's plan of care?
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Provide a structured environment with little stimuli.
