RN HESI Mental Health Exam

Extract:

Question 1 of 5

In conducting the initial assessment of a preoperative client, the nurse notes that the client's home medications include the monoamine oxidase (MAO) inhibitor phenelzine. Because of this client's medication history, which assessment finding is most important for the nurse to monitor?

Correct Answer: B

Rationale: MAO inhibitors like phenelzine can cause hypertensive crisis, making blood pressure monitoring critical. Other parameters are less directly affected.

Question 2 of 5

An adolescent client is admitted to the postoperative unit following open reduction of a fractured femur which occurred when the client fell down the stairs at a party. The nurse notices needle marks on the client's arms. Which assessment findings should the nurse document related to suspected narcotic withdrawal?

A. Vomiting, seizures, and loss of consciousness. B. Depression, fatigue, and dizziness. C. Hypotension, shallow respirations, and dilated pupils. D. Agitation, sweating, and abdominal cramps.

Correct Answer: D

Rationale: Agitation, sweating, and abdominal cramps are common symptoms of narcotic withdrawal. Other options are associated with overdose or other conditions.

Question 3 of 5

The nurse is planning the care for a client who is hospitalized with bipolar disorder. The client wanders the hallways, talks excessively, and makes sexual comments about the staff. Which intervention(s) should the nurse include in the plan of care? (Select all that apply.)

A. Invite for a walk when the client's energy is high. B. Engage the client in competitive activities. C. Assign the client to a single room. D. Provide television programs with suspense to keep attention engaged. E. Give concise and firm directions for hygiene and dressing.

Correct Answer: A,C,E

Rationale: Inviting for a walk channels excess energy, assigning a single room reduces stimuli, and giving concise directions provides structure. Competitive activities or suspenseful TV may escalate behaviors.

Question 4 of 5

A young female client is admitted to the emergency room because she was raped that evening by her date. Which computer documentation should the nurse enter in the electronic medical record as the client's chief complaint?

A. Client has been sexually assaulted. B. Client reported that she had sexual relations against her will. C. Client claims that she was forced to participate in sexual intercourse. D. Client states, 'My date raped me tonight.'

Correct Answer: D

Rationale: Client states, 'My date raped me tonight' is documented in the client's own words and is descriptive enough to be the presenting complaint capturing the urgency and trauma of the incident."

Question 5 of 5

A client who is an alcoholic receives a prescription for disulfiram 500 mg by mouth (PO) daily. Which instruction should the nurse provide to this client?

A. Take the medication with at least 8 ounces (240 mL) of water and limit alcohol consumption while taking this medication. B. Begin taking the medication immediately and take it daily, regardless of whether or not you drink alcohol. C. Take the medication at bedtime and avoid consuming any more than one ounce of alcohol daily. D. Take the medication each morning beginning 48 hours after your last drink of alcohol.

Correct Answer: D

Rationale: Disulfiram should be taken 48 hours after the last drink to prevent adverse reactions and is typically taken in the morning for adherence. Alcohol must be completely avoided.