Carolina is surprised when her patient does not show for a regularly scheduled appointment. When contacted, the patient states, 'I don't need to come see you anymore. I have found a therapy app on my phone that I love.' How should Carolina respond to this news?

Questions 43

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Mental Health HESI Questions

Question 1 of 9

Carolina is surprised when her patient does not show for a regularly scheduled appointment. When contacted, the patient states, 'I don't need to come see you anymore. I have found a therapy app on my phone that I love.' How should Carolina respond to this news?

Correct Answer: A

Rationale: Carolina should respond with choice A as it shows interest and willingness to understand the patient's new approach. By asking the patient to show the app, Carolina demonstrates openness to exploring the patient's perspective and the technology they find helpful. Choice B is incorrect as it appears dismissive, failing to acknowledge the patient's autonomy in choosing an alternative therapy method. Choice C is also inappropriate as it undermines the patient's decision-making and progress achieved so far. Choice D comes off as confrontational and judgmental, which could lead to the patient feeling defensive and less likely to engage in a constructive conversation.

Question 2 of 9

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?

Correct Answer: C

Rationale: The correct answer is C: 'Refusal to address nutritional needs.' In this scenario, the client's refusal to eat and address their nutritional needs poses an immediate threat to their physical health. Without proper nutrition, the client is at risk of malnutrition and its associated complications. While addressing social isolation, low self-esteem, and loss of interest in diversional activities are important aspects of holistic care for a client with depression, ensuring proper nutrition takes precedence due to the critical impact it has on the client's physical well-being. Therefore, the priority is to address the client's refusal to eat and address their nutritional needs to prevent further deterioration of their health.

Question 3 of 9

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?

Correct Answer: B

Rationale: Encouraging the client to suck on hard candy is the appropriate intervention as it can help alleviate the sensation of excessive thirst, which is a common side effect of lithium. Reporting the client's serum lithium level to the healthcare provider may be needed if there are signs of lithium toxicity, but the priority here is to address the immediate symptom of excessive thirst. Polydipsia, or excessive thirst, is a known side effect of lithium, but it should not be left unaddressed. Simply telling the client that drinking from the faucet is not allowed does not address the underlying issue of excessive thirst and may lead to further distress.

Question 4 of 9

A client is being educated by a healthcare professional about initiating a prescribed abstinence therapy using Disulfiram (Antabuse). What information should the client acknowledge understanding?

Correct Answer: B

Rationale: B: Before starting Disulfiram therapy, it is crucial for clients to be alcohol-free for a minimum of 12 hours to prevent adverse reactions. A: Admitting substance abuse is important, but it is not directly linked to the initiation of Disulfiram therapy. C: Attending Alcoholics Anonymous meetings is beneficial for support but not a specific requirement for starting Disulfiram. D: The focus of Disulfiram therapy is on alcohol abstinence, so abstaining from heroin or cocaine is not directly related to this medication.

Question 5 of 9

April, a 10-year-old admitted to inpatient pediatric care, has been getting more and more wound up and is losing self-control in the day room. Time-out does not appear to be an effective tool for April to engage in self-reflection. April's mother admits to putting her in time-out up to 20 times a day. The nurse recognizes that:

Correct Answer: B

Rationale: The correct answer is B: 'Time-out is no longer an effective therapeutic measure.' In this scenario, the excessive use of time-out, up to 20 times a day, indicates that it is no longer effective in helping April self-reflect and control her behavior. Constant use of time-out without achieving the desired outcome suggests the need for alternative therapeutic interventions. Choice A is incorrect because the situation described indicates that time-out is not serving its intended purpose. Choice C is also incorrect as the behavior is not driven by a desire for alone time. Choice D is incorrect and inappropriate as seclusion and restraint should only be considered as a last resort and are not indicated based on the information provided.

Question 6 of 9

A male client is admitted to the psychiatric inpatient unit with a bandaged flesh wound after attempting to shoot himself. He was divorced one year ago, lost his job four months ago, and suffered a breakup of his current relationship last week. What is the most likely source of this client's current feelings of depression?

Correct Answer: B

Rationale: The client's recent history of divorce, job loss, and breakup of a current relationship indicates a series of significant losses. These losses are likely the primary source of his feelings of depression, leading to a sense of loss. While feelings of frustration (choice A) and poor self-esteem (choice C) could be contributing factors, the immediate trigger for his current emotional state appears to be the series of losses. A lack of intimate relationships (choice D) may be a consequence of the client's depressive symptoms rather than the root cause in this scenario.

Question 7 of 9

A client who has agoraphobia (a fear of crowds) is starting desensitization therapy with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care?

Correct Answer: B

Rationale: Establishing trust by providing a calm and safe environment is crucial for the success of desensitization therapy in clients with agoraphobia. This approach helps the client feel safe and secure, allowing them to gradually confront their fear of crowds. Encouraging positive thoughts (choice A) is beneficial but not as immediately critical as creating a safe space. Progressively exposing the client to larger crowds (choice C) should occur after trust is established and in a controlled manner. Encouraging deep breathing (choice D) is helpful, but creating a safe environment takes precedence to build a foundation for successful desensitization.

Question 8 of 9

A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The RN also determines that the client is homeless and is exhibiting suspiciousness. The client's plan of care should include what priority problem?

Correct Answer: A

Rationale: Acute confusion is the priority problem because it directly impacts the client's safety and functioning. In this scenario, the client is disoriented, disorganized, and confused, which can pose immediate risks to her well-being. Ineffective community coping, disturbed sensory perception, and self-care deficit are not as urgent in this situation. Ineffective community coping focuses on the client's ability to manage stress related to the community, disturbed sensory perception pertains to alterations in sensory input, and self-care deficit involves the inability to perform activities of daily living independently. While these issues may also need addressing, acute confusion takes precedence due to the immediate safety concerns it presents.

Question 9 of 9

A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. What intervention is best for the nurse to implement?

Correct Answer: D

Rationale: The best intervention for a male client with schizophrenia displaying echolalia, which is disruptive to others, is for the nurse to escort the client to his room. Echolalia, the constant repetition of others' words, can be disruptive in a communal setting. By guiding the client to a private space like his room, the nurse helps manage the behavior without isolating or medicating the client unnecessarily. Avoiding acknowledging the behavior (Choice A) does not address the issue, isolating the client (Choice B) may exacerbate feelings of exclusion, and administering a PRN sedative (Choice C) should be reserved for situations where there is imminent risk or severe agitation, not for managing echolalia.

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