RN HESI Mental Health 2023

Extract:

Question 1 of 5

A client engages in repeated checks of door and window locks and behavior that prevents the client from arriving on time and interfering with the ability to function effectively. Which action should the nurse take?

Correct Answer: B

Rationale: Planning a list of daily activities helps establish a structured routine, reducing time spent on compulsive checking and promoting effective functioning. Determining lock types is irrelevant. Discussing time-checking does not address lock-checking. Asking 'why' may increase frustration, as compulsive behaviors are anxiety-driven.

Question 2 of 5

The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. Which information should the nurse explore in depth with the client based on this screening tool?

A. Efforts to cut down, annoyance with questions, guilt, drinking as an 'Eye-opener' B. Consumption, liver enzyme, gastrointestinal complaints and bleeding C. Cancer screening results, anger, gastritis, daily alcohol intake D. Minimizes drinking, frequently misses family events, guilt about drinking, amount of daily intake

Correct Answer: A

Rationale: The CAGE questionnaire focuses on four key aspects: efforts to Cut down, Annoyance with questions, Guilt about drinking, and Eye-opener use. Exploring these provides insight into potential alcohol problems. Other options include relevant aspects but are not specific to the CAGE questionnaire.

Question 3 of 5

A client is admitted to the mental health unit with a bipolar disorder. When seeking to establish a therapeutic relationship and interacting with the client, which comment is best for the nurse to make?

A. I understand that you're angry and unhappy. Let's explore ways in which you overreact B. I hear your frustration about losing control. Tell me how this affects your daily life C. Knowing the cause of your symptoms will make them easier to handle D. Do all that you can to learn all that you can while you are here. You can get better

Correct Answer: B

Rationale: This response acknowledges the client's feelings and invites further exploration, fostering a therapeutic relationship. The first option may invalidate feelings by assuming overreaction. The third shifts focus from immediate concerns. The fourth is encouraging but does not address current feelings.

Question 4 of 5

When the nurse addresses questions to an adult client who is depressed, the client's responses are delayed. Which intervention should the nurse include in the client's plan of care?

A. Involve client in daily exercise program B. Ask the client to describe her depression C. Spend time sitting in silence with client D. Observe for signs of possible psychosis

Correct Answer: C

Rationale: Spending time sitting in silence with the client provides a supportive presence without pressure for immediate responses, which is helpful for depression-related delays in communication. Exercise may be beneficial but does not address delayed responses directly. Asking about depression is useful for assessment but not immediate needs. Observing for psychosis is not indicated unless other symptoms are present.

Question 5 of 5

A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?

A. Concentrate on and ventilate emotions when distressed B. Relax and reduce the amount of effort to solve the problem C. Shift attention from self to the needs and requests of others D. Focus on small achievable tasks, not taxing problems

Correct Answer: D

Rationale: Focusing on small achievable tasks promotes a sense of accomplishment, counteracting helplessness and supporting behavioral activation for depression. Ventilating emotions may not address avoidance. Reducing effort may worsen helplessness. Shifting attention to others does not directly address depressive symptoms.