TEST BANK FOR HESI MENTAL HEALTH
RN V1-V3|| 100% VERIFIED|A+ RATED.
A patient with depression remains in bed most of the day, and declines
activities. Which nursing problem has the greatest priorityfor this patient?
• Loss of interest in diversional activity.
• Social isolation.
• Refusal to address nutritional needs.
• Low self-esteem.
The RN is preparing medications for a patient with bipolar disorder and notices
that the patient discontinued antipsychotic medication for several days. Which
medication should also be discontinued?
• Lithium. (Lithotabs)
• Benzotropine (Cogentin).
• Alprazolam (Xanax).
• Magnesium (Milk of Magnesia).
A female patient requests that her husband be allowed to stay in theroom
during the admission assessment. When interviewing the patient, the RN
notes a discrepancy between the patient’s verbal and nonverbal
communication.
What action does the RN take?
• Pay close attention and document the nonverbal messages.
• Ask the patient’s husband to interpret the discrepancy.
• Ignore the nonverbal behavior and focus on the patient’sverbal
messages.
• Integrate the verbal and nonverbal messages and interpretthem as
one.
A male patient approaches the RN with an angry expression on his face and
raises his voice, saying “My roommate is the most selfish, self-centered, angry
person I have ever met. If he loses his temperone more time with me, I am
going to punch him out!” The RN recognizes that the patient is using which
defense mechanism?
A.
Deni
al.B.

Projection
.
C. Rationalization.
D. Splitting.
A male patient with bipolar disorder who began taking lithium carbonate five
days ago is complaining of excessive thirst, and theRN finds him attempting to
drink water from the bathroom sink faucet. Which intervention should the RN
implement?
• Report the patient’s serum lithium level to the HCP.
• Encourage the patient to suck on hard candy to relieve thesymptoms.
• No action is needed since polydipsia is a common side effect.
• Tell the patient that drinking from the faucet is not allowed.
The RN is teaching a patient about the initiation of the prescribed abstinence
therapy using disulfiram (Antabuse). What informationshould the patient
acknowledge understanding?
• Completely abstain from heroin or cocaine use.
• Remain alcohol free for 12 hours prior to the first dose.
• Attend monthly meetings of alcoholics anonymous.
• Admit to others that he is a substance user.
A male patient with schizophrenia is admitted to the mental health unit after
abruptly stopping his prescription for ziprasidone (Geodon) one month ago.
Which question is most important for theRN to ask the patient?
• Have you lost interest in the things that you used to enjoy?
• Is your ability to think or concentrate decreased?
• How many continuous hours do you sleep atnight? D.
Do you hear sounds or voices that others do not hear?
During an annual physical by the occupational RN working in a corporate
clinic, a male employee tells the RN that is high-stress jobis causing trouble in
his personal life. He further explains that he often gets so angry while driving
to and from work that he has considered “getting even” with other drivers.
How should the RN respond?
• “Anger is contagious and could result in major confrontation.”
• “Try not to let your anger cause you to act impulsively.”
• “Expressing your anger to a stranger could result inan unsafe
situation.”
• “It sounds as if there are many situations that make you feelangry.”

A patient who has agoraphobia (a fear of crowds) is beginning desensitization
with the therapist, and the RN is reinforcing the process. Which intervention has
the highest priority for this patient’s plan of care?
• Encourage substitution of positive thoughts and negative ones.
• Establish trust by providing a calm, safe environment.
• Progressively expose the patient to larger crowds.
• Encourage deep breathing when anxiety escalates in a crowd.
Which nursing actions are likely to help promote the self-esteem of amale patient
with modern depression?
• Ask the patient what his long term goals are.
• Discuss the challenges of his medical condition.
• Include the patient in determining treatment
protocol. D. Encourage the patient to engage in
recreational therapy.
E. Provide opportunities for the patient to discuss his concerns.
A male patient is admitted to the psychiatric unit for recurrent negative
symptoms of chronic schizophrenia and medication adjustment of Risperidone
(Risperdal). When the patient walks to thenurse’s station in a laterally contracted
position, he states that something has made his body contort into a monster.
What action should the RN take?
• Medicate the patient with the prescribed antipsychotic
thioridazine (Mellaril).
• Offer the patient a prescribed physical therapy hot pack for
muscle spasms.
• Direct patient to occupational therapy to distract him from
somatic complaints.
• Administer the prescribed anticholinergic benztropine
(Cogentin) for dystonia.
A mental health worker is caring for a patient with escalating aggressive
behavior. Which action by the MHW warrant immediateintervention by the
RN?
• Is attempting to physically restrain the patient.
• Tells the patient to go to the quiet area of the unit.
• Is using a loid voice to talk to the patient.
• Remains at a distance of 4 feet from the patient.

A patient on the mental health unit is becoming more agitated, shouting at the
staff, and pacing in the hallway. When the PRN medication is offered, the
patient refuses the medication and defiantlysits on the floor in the middle of
the unit hallway. What nursing intervention should the RN implement first?
• Transport of the patient to the seclusion room.
• Quietly approach the patient with additional staff members.
C. Take other patients in the area to the patientlounge.
D. Administer medication to chemically restrain the patient.
A patient is admitted to the mental health unit and reports taking extra antianxiety
medication because, “I’m so stressed out. I just want to go to sleep.” The RN
should plan one-on-one observation of the patientbased on which statement?
• “What should I do? Nothing seems to help.”
• “I have been so tired lately and needed to sleep.”
• “I really think that I don’t need to be here.”
• “I don’t want to walk. Nothing matters anymore.”
A male hospital employee is pushed out the way by a female employee because
of an oncoming gurney. The pushed employee becomes very angry and swings
at the female employee. Both employees are referred for counseling with the
staff psychiatric RN. Which factor in the pushed employee’s history is most
related to thereaction that occurred?
• Is worried about losing his job to a woman.
• Tortured animals as a child.
• Was physically abused by his mother.
• Hates to be touched by anyone.
The RN documents the mental status of a female patient who has been
hospitalized for several days by court order. The patient states, “Idon’t need to
be here” and tells the RN that she believes the television talks to her. The RN
should document these assessment findings in which section of the mental
status exam/
A. Level of
concentration. B. Insight
and judgement.
C. Remote memory.
D. Mood and affect.
A patient is admitted to the mental health unit reports shortness of breath and
dizziness. The patient tells the RN, “I feel like I’m going to die”. Which nursing
problem should the RN include in this patient’s planof care?

A. Mood
disturbance. B.
Moderate anxiety.
C. Altered thoughts.
D. Social isolation.
A female patient who is wearing dirty clothes and has foul body odor,comes to
the clinic reporting feeling scared because she is being stalked. What action is
most important for the RN to take?
• Offer the patient a safe place to relax before interviewing her.
• Ask the patient to describe why she is being stalked.
• Recommend that the patient talk with a social worker.
• Assure the patient that the HCP will see her today.
The RN leading a group session of adolescent patients gives the members a handout
about anger management. One of the male patients is fidgety, interrupts peers when
they try and talk, and talksabout his pets at home. What nursing action is best for the
RN to take?
• Explore the patient’s feelings about his pets and home life.
• Encourage his peers to help involve him in the activity.
• Give the patient permission to leave and return in 10
minutes. D. Redirect him by encouraging him to readfrom the
handout.
A male adolescent was admitted to the unit two days ago for depression. When the
mental health RN tries to interview the patient toestablish rapport, he becomes
very irritated and sarcastic. Which action is best for the RN to take?
• Report the behavior to the next shift.
• Offer to play a game of cards with the patient.
• Document the behavior in the chart.
• Plan to talk with the patient the next day.
A male adult is admitted because of an acetaminophen (Tylenol) overdose.
After transfer to the mental health unit, the patient is told he has liver
damage. Which information is most important for the nurse to include in the
patient's discharge plan?
• Do not take any over the counter meds.
• Eat a high carb, low fat, low protein diet.
• Call the crisis hotline if feeling lonely.
• Avoid exposure to large crowds.

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After receiving treatment for anorexia, a student asks the schoolRN for
permission to work in the school cafeteria as part of the school’s work study
program. What action should the RN take?
A. Refer the student to a psychiatrist for furtherdiscussion. B.
Recommend assignment to the receptionist’s office.
C. Suggest that student work in the athletic department.
D. Determine the parent’s opinion of the work assignment.
The Rn accepts a transfer to the metal health unit and understandsthat the
patient is distractible and is exhibiting a decreased ability to concentrate. The
RN only has 15 minutes to talk to the patient. To develop treatment plan for
this patient, which assessment is most important for the RN to obtain?
• Motivation of treatment.
• History of substance use.
• Medication
compliance. D. Mental
status examination.
A male patient who recently lost a loved one arrives at the mental health
center and tells the RN he is no longer interested is his usualactivities and has
not slept for several days. Which priority nursing problem should the RN
include in the patient’s plan of care?
A. Risk for suicide.
B. Sleep
deprivation.
C. Situational low self-esteem.
D. Social isolation.
A male patient with long history of alcohol dependency arrives in the
emergency department describing the feelings of bugs crawling onhis body.
His blood pressure is 170/102, his pulse rate is 110 bpm, and is blood alcohol
level is 0mg/dL. Which prescription should the RN administer?
• Haloperidol (Haldol).
• Thiamine (Vitamin B1).
• Diphenhydramine (Benadryl).
• Lorazepam (Ativan).

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A patient who refuses antipsychotic medications disrupts group activities,
talks with nonsensical words and wanders into patient’s rooms. The RN
decides that the patient needs constant observationbased on which of these
assessment findings?
• Wanders into the patients rooms.
• Refuses antipsychotic medications.
• Talks with nonsensical words.
• Disrupts group activities.
A patient with schizophrenia explains that she has 20 children and then very
seriously points to the RN and explains that she is one of them. What is the
most therapeutic response for the RN to provide/
A. “Let’s go ask another RN is this is true.” B.
“My name tag shows that I ama RN here.”
C. “I can’t possibly be one if your children.”
D. “I know that you don’t have 20 children.”
A high school girl reveals to the high school RN that she has beenengaging in
self-induced vomiting as weight-control measure. Whichinitial assessment
should the RN focus on with this adolescent?
• National percentile of weight and height.
• Frequency of bingeing and purging behaviors.
• Perceptions of family and social relationships.
• School grades and extracurricular activities.
Narcan was administered to an adult patient following a suicide attempt with an
overdose of hydrocodone bitartrate (Vicodin). Within15 minutes, the patient is
alert and oriented. In planning nursing care,which intervention has the highest
priority at this time?
• Encourage the patient to increase fluid intake.
• Obtain the patient’s serum Vicodin level.
• Observe the patient for further narcotic effects.
• Determine the patient’s reason for attempting suicide.

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Following surgery, a male patient with antisocial personality disorder
frequently requests that a specific RN be assigned to is care and isbelligerent
when another RN is assigned. What action should the charge RN implement?
• Reassure the patient that his request will be met whenever
possible.
• Advise the patient that assignments are not based on the
patient’s request.
• Ask the patient to explain why he constantly requests the RN.
• Encourage the patient to verbalize his feelings about the RN.
When preparing to administer a prescribed medication to a homelessmale at a
community clinic, the patient tells the RN that he usually takes a different dosage.
What action should the RN take?
• Tell him to take the medication then verify the dosage atthe
next healthcare team meeting.
• Withhold the medication until the dosage can be confirmed.
• Inform him that he may refuse the medication and documentwhether or
not he takes it.
• Explain to the patient that the dosage has been changed.
The nurse orients a female patient with depression to the new room on the mental
health unit. The patient states “It seems strange that I don’thave a T.V in my
room.” Which statement would be best for the RN to provide?
• “You can watch T.V as much as you want outside of your room.”
• “Sometimes patients feel like the T.V is sending them
messages.” C. “It’s important to be out of you room andtalking
to others.”
D. “Watching T.V is a passive activity and we want you to beactive.”
A patient admitted with a closed head injury after a fall has a blood alcohol level
of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6
hours following admission should theRN identify as the priority?

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• Give lorazepam (Ativan) PRN for signs of withdrawal.
• Administer disulfiram (Antabuse) immediately.
• Place in a side lying position with head of bed elevated.
• Provide thiamine and folate supplements as prescribed.
The RN is completing the admission assessment of an underweight
adolescent who is admitted to a psychiatric unit with a diagnosis of
depression. Which finding requires notification to the HCP?
• Potassium level of 2.9 mEq/dl.
• Blood pressure of 110/70 mmHg.
• WBC of 10,000mm^3.
• Body mass index of 21.
The Rn is planning patient teaching for a 35-year-old patient with alcoholic
cirrhosis. Which self-care measure should the RN emphasizefor the patient’s
recovery?
• Support group meetings.
• Vitamin B and multivitamin supplements.
• Diet with adequate calories and protein.
• Alcohol abstinence.
A teenager has lost 20 pounds in the last three months is admittedto the
hospital with hypotension and tachycardia. The patient reportsirregular
menses and hair loss. Which intervention is most important for the RN to
include in the patients plan of care?
• Implement behavioral modification therapy.
• Initiate caloric and nutritional therapy.
• Evaluate the patient for low self-esteem.
• Record daily weights and graft trend.

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While interviewing a patient, the nurse takes notes to assist with accurate
documentation later. Which statement is most accurateregarding note- taking
during an interview?
• The patient’s comfort level is increased when the RN breaks eyecontact to
take notes.
• The interview process is enhanced with note taking andallows
the patient to speak at a normal pace.
• Taking notes during an interview is a legal obligation ofexamining
RN.
• The RN’s ability to directly observe the patient’s non-
verbal communication is limited with note taking.
A patient is receiving substitution therapy during withdrawal from
benzodiazepines. Which expected outcome statement has the highest priority
when planning nursing care?
• patient will not demonstrate cross addiction.
• Co-dependent behaviors will be decreased.
• CNS stimulation will be reduced.
• patient's level of consciousness will increase.
A patient who is being treated with lithium carbonate for manic depression
begins to develop diarrhea, vomiting, and drowsiness.What action should the
nurse take?
• Notify the physician immediately and force fluids.
• Prior to giving the next dose, notify the physicianof the
symptoms.
• Record the symptoms and continue medication as
prescribed.
• Hold the medication and refuse to administer additional
amounts of the drug.

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2023 HESI RN Mental Health Test Bank Version 1 With Answers (143 Solved Questions)

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