RN HESI Mental Health Exam

Extract:

Question 1 of 5

When responding to a call light, the nurse finds a client with aggressive behaviors pacing and restless in the room. The client shouts, 'What took you so long to get in here!' Which action should the nurse implement?

Correct Answer: A

Rationale: Providing personal space allows the client to feel less threatened and reduces the risk of escalation. Standing in the doorway, requesting backup, or encouraging sitting may escalate the situation.

Question 2 of 5

A young adult client with a recent diagnosis of bipolar disorder takes lithium carbonate daily. The client informed the school nurse of the desire to live away from home to attend college after graduating in one month. Which information is most important for the nurse to provide the client and his family?

A. The client should be aware of the signs and symptoms of his illness. B. The client's serum lithium levels should be routinely evaluated. C. The client should plan to participate in group or individual therapy while at college. D. Despite the illness, the client should be able to live away from home.

Correct Answer: B

Rationale: Monitoring serum lithium levels is essential to ensure the medication remains within the therapeutic range and to prevent toxicity, critical for a newly diagnosed client.

Question 3 of 5

A female client who is a retired school teacher is admitted for a breast biopsy. After being told that the biopsy was positive for cancer, she becomes dependent and asks her family for help with activities of daily living that she is physically capable of performing. Which interpretation of this client's behavior by the nurse is likely to be most accurate?

A. Expected, as the client is attempting to reduce anxiety by regressing to a state of lesser anxiety. B. Should be encouraged as representative of the client's non-destructive method of fear expression. C. Unacceptable, and limits should be set to encourage the client to maintain her independence. D. Should be accepted by staff as the first step the client must experience in the grieving process.

Correct Answer: A

Rationale: This behavior is a regression to reduce anxiety, a common response to a cancer diagnosis. Encouraging dependency, setting rigid limits, or viewing it solely as grieving may not address the client's emotional needs.

Question 4 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.

Question 5 of 5

The nurse is assessing a client whose spouse died of a stroke two weeks ago and who reports having numbness and tingling on the right side of the body. The nurse should consider the client's symptoms may likely be due to which condition?

A. Disorganization. B. Preoccupation. C. Somatization. D. Reexperience.

Correct Answer: C

Rationale: Somatization involves psychological distress manifesting as physical symptoms like numbness and tingling after a traumatic loss. Other options are less relevant.