HESI RN
RN Hesi Mental Health Exam 1 Questions
Extract:
Question 1 of 5
During the initial nursing interview, a client tells the nurse, 'Sometimes my thoughts go so fast. Wonder if I can sell my fast car. Work is so boring. I wonder if I can get a transfer. Is it time to eat yet?' Which documentation should the nurse enter in the electronic medical record to describe the client's statements?
Correct Answer: B
Rationale: Tangential thinking involves moving between unrelated topics without conclusion, as seen in the client's statements. Thought-blocking, word salad, and incoherent speech do not apply.
Question 2 of 5
A client who has been taking clozapine reports experiencing a sore throat and has a temperature of 101.9° F (38.8° C). Which action should the nurse take?
Correct Answer: B
Rationale: Clozapine can cause agranulocytosis, and a sore throat with fever may indicate this. A complete blood count is essential to assess for this life-threatening condition. Other actions are less urgent.
Question 3 of 5
A middle-aged female client with no previous psychiatric history is seen in the mental health clinic because her family describes her as having paranoid thoughts. On assessment, she tells the nurse, 'I want to find out why these people are stalking me!' Which response should the nurse provide?
Correct Answer: B
Rationale: Encouraging elaboration on the client's beliefs provides insight into her delusions without confrontation, aiding assessment. Other responses may escalate distress or invalidate feelings.
Question 4 of 5
When preparing to administer a domestic violence screening tool to a female client, which statement should the nurse provide?
Correct Answer: C
Rationale: Explaining that screening is routine due to the prevalence of domestic abuse normalizes the process and encourages disclosure. Other statements may assume abuse or feel coercive.
Question 5 of 5
When assessing a female client who has been taking an antipsychotic medication for the past year, the nurse observes that the client demonstrates involuntary foot tapping while both feet are flat on the floor. The nurse plans to report the observation to the healthcare provider. Which additional action should the nurse take?
Correct Answer: A
Rationale: Involuntary foot tapping may indicate tardive dyskinesia, a side effect of antipsychotics. Documenting on the AIMS allows systematic monitoring. Other actions misattribute the symptom or are irrelevant.