HESI RN
RN HESI Mental Health 2023 Questions
Extract:
Question 1 of 5
The nurse documents that a client with schizophrenia is delusional. Which statement by the client confirms this assessment?
Correct Answer: B
Rationale: The nurse at night is trying to poison me with pills' confirms a delusion, specifically a paranoid delusion, as it reflects a fixed, false belief not based in reality. The other options describe hallucinations: visual ('snakes'), auditory ('voices'), and tactile ('fire'). Delusions involve false beliefs, while hallucinations involve false sensory perceptions.
Question 2 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?
Correct Answer: D
Rationale: Client states, 'My date raped me tonight' is the most accurate and objective, using the client's own words to document the chief complaint without implying doubt ('claims') or minimizing the trauma. 'Sexual assault' is accurate but less specific.
Question 3 of 5
A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?
Correct Answer: B
Rationale: The client's delusions (e.g., being married to a movie star, brother's intentions) indicate disturbed sensory perception, suggestive of psychosis, which is the priority. Ineffective sexual patterns are not directly indicated. Family coping may be secondary. Impaired environmental interpretation is too broad.
Question 4 of 5
Which intervention(s) should the nurse include in the plan of care for an adolescent client who is depressed? Select all that apply.
Correct Answer: B,C,D
Rationale: B: Reinforcing statements about a will to live provides hope. C: Discussing a suicide plan assesses risk and ensures safety. D: Encouraging discussion of thoughts and feelings promotes therapeutic communication. A: Restricting visitors may increase isolation. E: Limiting video games is less relevant to immediate depression management.
Question 5 of 5
A client with a history of alcoholism is admitted for detoxification. Based on treatment protocol, the nurse gives the client a dose of lorazepam 6 mg. Which additional prescription should the nurse administer immediately?
Correct Answer: D
Rationale: Vitamin B1 (thiamine) is crucial in alcohol detoxification to prevent Wernicke's encephalopathy and Korsakoff's syndrome due to thiamine deficiency. Folic acid is beneficial but not immediate. Haloperidol and trazodone are not indicated for detoxification.