HESI RN
Quizlet HESI Mental Health Questions
Question 1 of 5
The RN documents the mental status of a female client who has been hospitalized for several days by court order. The client states, "I don't need to be here," and tells the RN that she believes that the TV talks to her. The RN should document these assessment statements in which section of the mental status exam?
Correct Answer: A
Rationale: The client's statement of not needing to be hospitalized and her belief that the TV talks to her indicate impaired insight and judgment. Insight and judgment evaluate the client's awareness of their condition and ability to make sound decisions. Mood and affect assess emotional state, remote memory evaluates recall of past events, and level of concentration assesses attention and focus, none of which directly address the client's lack of insight and judgment in this scenario.
Question 2 of 5
The RN is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? (SOA)
Correct Answer: B
Rationale: B: Establishing a code with family and friends is important as it helps discreetly communicate the need for help without alerting the abuser. D: Having a bag prepared with essentials ensures the victim can swiftly leave if required. A: Purchasing a gun can escalate violence and is not a recommended safety strategy. C: Taking a self-defense course focused on protecting oneself is beneficial, but courses that involve retaliation are not recommended as they can increase risk and escalate violence.
Question 3 of 5
While working with a male client at a community mental health center, the client reports hearing voices that tell him to get a knife from the kitchen and hurt himself. What intervention is most important for the RN to implement?
Correct Answer: A
Rationale: Preventing the client's access to potential means of self-harm is the immediate priority to ensure his safety. While it is crucial to report concerning behaviors to the client's case workers for further support, addressing the immediate risk of harm takes precedence. Assigning a UAP to stay with the client is important for continuous monitoring but is secondary to ensuring immediate safety. Documenting the behavior in the client's record and notifying the healthcare provider are essential steps in the care process; however, they should follow actions taken to ensure the client's immediate safety.
Question 4 of 5
What intervention is best for the nurse to implement for a male client with schizophrenia who is demonstrating echolalia, which is becoming annoying to other clients on the unit?
Correct Answer: D
Rationale: Echolalia, the constant repetition of what others are saying, can be disruptive to the therapeutic environment. The most appropriate intervention is to escort the client to his room. This action provides the client with a private space where he can engage in the behavior without disturbing other clients. Avoiding recognition of the behavior (Choice A) may not address the issue and could lead to increased annoyance among other clients. Isolating the client (Choice B) may have negative psychological effects and should be avoided unless absolutely necessary for safety concerns. Administering a PRN sedative (Choice C) should be considered only as a last resort and if other de-escalation techniques have been unsuccessful.
Question 5 of 5
A female client, who is wearing dirty clothes and has a foul body odor, comes to the clinic reporting feeling scared because she is being stalked. What action is most important for the nurse to take?
Correct Answer: D
Rationale: The most important action for the nurse to take in this scenario is to offer the client a safe place to relax before interviewing her. The client's disheveled appearance and foul body odor suggest she may be in distress or facing challenging circumstances. By providing her with a safe and comfortable environment to relax, the nurse can help alleviate some of her distress and establish trust. This approach is crucial as the client is already feeling scared due to being stalked, indicating underlying mental health concerns. Assuring the client of a healthcare provider visit (choice A) may not address her immediate need for safety and comfort. Recommending she talk with a social worker (choice B) may be beneficial later but does not address the immediate need for a safe space. Asking the client to describe why she is being stalked (choice C) is not appropriate as the priority is ensuring her safety and comfort first.