RN HESI Mental Health Exam

Extract:

Question 1 of 5

Following the visit, what are appropriate actions for the nurse? Select all that apply.

Correct Answer: B,C,E

Rationale: Providing referrals for mental health services, following up with the client, and documenting verbatim statements about abuse are appropriate actions to support the client and ensure accurate records. Mailing items without consent or calling the police without an immediate threat are less appropriate.

Question 2 of 5

The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?

A. Hallucinations and delusions. B. Stimulation and dilated pupils. C. Lethargy and depression. D. Bradycardia and bradypnea.

Correct Answer: B

Rationale: Cocaine use commonly causes stimulation and dilated pupils. Hallucinations, lethargy, or bradycardia are associated with other conditions or substances.

Question 3 of 5

The nurse is caring for a client who is experiencing extreme sadness after the passing of a companion of 30 years. The client describes not being able to think of other things and finds it difficult to control emotions. Which action should the nurse take first?

A. Explore changes in life that have occurred after the loss. B. Suggest the need for a psychiatric consultation. C. Offer a referral to pastoral counseling. D. Encourage attending a local support group.

Correct Answer: A

Rationale: Exploring changes in life after the loss helps the nurse understand the client's current situation and provides a basis for further interventions. Other actions are secondary to assessing the client's needs.

Question 4 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. Shift attention from self to the needs and requests of others B. Relax and reduce the amount of effort to solve the problem. C. Focus on small achievable tasks, not taxing problems. D. Concentrate on and ventilate emotions when distressed.

Correct Answer: C

Rationale: Focusing on small achievable tasks helps in breaking down overwhelming problems into manageable parts, aiding in a sense of accomplishment. Shifting attention to others may strain the client further, relaxation without addressing issues may worsen depression, and solely ventilating emotions does not address handling responsibilities.

Question 5 of 5

The nurse documents that a male client with schizophrenia is delusional. Which statement by the client confirms this assessment?

A. The snakes on the wall are going to eat me.' B. The voices are telling me to kill the next person I see.' C. The nurse at night is trying to poison me with pills.' D. The fire is burning my skin away right now.'

Correct Answer: C

Rationale: The nurse at night is trying to poison me with pills' reflects a persecutory delusion, a false belief characteristic of delusional thinking in schizophrenia. Other statements indicate hallucinations.