HESI RN Mental Health Exam

HESI RN Mental Health Exam

VERSION 17

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A nurse is told during change of shift report that a client is stuporous. When assessing the client, which of the following findings should the nurse expect?

• The client arouses briefly in response to a sternal rub.
• The client has a glasgow coma scale score less than 7.
• The client exhibits decorticate rigidity.
• The client is alert but disoriented to time and place.

A nurse is planning a peer group discussion about the DSM-5. Which of the following information is appropriate to include in the discussion? (Select all that apply)

• The DSM-5 includes client education handouts for mental health disorders.
• The DSM-5 establishes diagnostic criteria for individual mental health disorders.
• The DSM-5 indicates recommended pharmacological treatment for mental health disorders.
• The DSM-5 assists nurses in planning care for client's who have mental health disorders.
• The DSM-5 indicates expected assessment findings of mental health disorders.

A nurse in an emergency mental health facility is caring for a group of clients. The nurse should identify that which of the following clients requires a temporary emergency admission?

• A client who has schizophrenia with delusions of grandeur
• A client who has manifestations of depression and attempted suicide a year ago
• A client who has borderline personality disorder and assaulted a homeless man with a metal

rod

• A client who has bipolar disorder and paces quickly around the room while talking to himself

A nurse decides to put a client who has a psychotic disorder in seclusion overnight because the unit is very short-staffed, and the client frequently fights with other clients. The nurse's actions are an example of which of the following torts?

• Invasion of privacy
• False imprisonment 2 / 3

• Assault
• Battery

A client tells a nurse, "Don't tell anyone but I hid a sharp knife under my mattress in order to protect myself from my roommate, who is always yelling at me and threatening me." Which of the following actions should the nurse take?

• Keep the client's communication confidential, but talk to the client daily, using therapeutic

communication to convince him to admit to hiding the knife.

• Keep the client's communication confidential, but watch the client and his roommate closely.
• Tell the client that this must be reported to the health care team because it concerns the

health and safety of the client and others.

• Report the incident to the health care team, but do not inform the client of the intention to do

so.

A nurse is caring for a client who is in mechanical restraints. Which of the following statements should the nurse include in the documentation? (Select all that apply)

• "Client ate most of his breakfast."
• "Client was offered 8 oz of water every hr."
• "Client shouted obscenities at assistive personnel."
• "Client received chlorpromazine 15 mg by mouth at 1000."
• "Client acted out after lunch."

A nurse hears a newly licensed nurse discussing a client's hallucinations in the hallway with another nurse. Which of the following actions should the nurse take first?

• Notify the nurse manager.
• Tell the nurse to stop discussing the behavior.
• Provide an in-service program about confidentiality.
• Complete an incident report.
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