HESI RN
RN Psychology Mental Health NGN Questions
Question 1 of 5
An adolescent female arrives at the wellness clinic reporting fears that she will hurt herself. The nurse observes scars on both wrists of the client. Which priority action should the nurse implement?
Correct Answer: A
Rationale: The client's statement about self-harm and the physical evidence of past self-harm (scars) indicate an immediate and acute risk to her safety. The priority nursing action is to conduct a formal risk assessment to determine the current level of suicidal ideation, intent, and plan, which is essential for implementing appropriate safety measures. Assessing for body image disturbance, while potentially relevant, does not address the imminent safety concern. Praising the client, though supportive, is not the most critical intervention when a risk assessment is pending. Exploring life events is important for understanding context, but it is secondary to ensuring the client's immediate physical safety.
Question 2 of 5
The CAGE questionnaire asks four questions and is a widely used to screen for alcoholism. Which of the four questions included in the CAGE questionnaire is most indicative of alcoholism?
Correct Answer: C
Rationale: This question points to physiological dependence, specifically tolerance and withdrawal symptoms. Needing a drink in the morning (an "eye-opener") to function or avoid withdrawal is a strong clinical indicator of alcohol dependence, moving beyond psychological or social concerns into the realm of physical addiction. Feeling the need to cut down, feeling annoyed by criticism, or feeling guilt are common experiences that can occur in earlier stages of problematic drinking or even in heavy drinkers without full dependence, making them less specific markers for alcoholism.
Question 3 of 5
A young adult is brought to the emergency room by friends who tells the nurse that the client has ingested a large amount of phencyclidine (PCP). Which action(s) should the nurse include in the client's plan of care? Select all that apply.
Correct Answer: A, D, E
Rationale: A quiet, non-stimulating environment (
A) is essential to prevent agitation and violent reactions, which are common with PCP intoxication. Acknowledging hallucinations (
D) helps build rapport and de-escalate fear without reinforcing delusions. Seizure precautions (E) are a critical safety measure due to the risk of seizures from a large PCP overdose. In contrast, using restraints (
B) can dramatically increase agitation and the risk of physical complications like rhabdomyolysis, and encouraging large fluid intake (
C) is dangerous due to PCP's common side effect of urinary retention.
Question 4 of 5
A client is admitted to the hospital with suicidal ideation. When completing the health history and admission assessment interview, which client comment is most important for the nurse to document?
Correct Answer: D
Rationale: The presence of firearms in the home, even if reportedly locked, represents the single greatest risk factor for a completed suicide due to the lethality of the method. While feelings of emptiness, a single protective factor, and panic attacks are important clinical details, they do not indicate the same level of immediate, concrete danger as access to a highly lethal means.
Question 5 of 5
A client with depression is not attentive to personal hygiene, uses television watching as a means of escape from responsibilities. and describes an inability to enjoy the things that once gave them pleasure. Which coping strategy should the nurse include in the plan of care?
Correct Answer: B
Rationale: The client's current coping (escapism, withdrawal) is maladaptive. Guiding the client to recall and re-implement strategies that were previously successful encourages the use of proven, healthy coping mechanisms and helps rebuild a sense of self-efficacy, which is often eroded in depression. Reaching out about abandonment (
A) may not be feasible or therapeutic if social withdrawal is a symptom, and "relaxing" (
C) reinforces the existing passive avoidance. Simply turning to other activities (
D) is the client's current maladaptive pattern (TV watching) and does not address the core issue of anhedonia or help the client re-engage with meaningful responsibilities.