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HESI Mental Health
1. The nurse documents that a male client with paranoid schizophrenia is delusional. Which statement by the client confirms this assessment?
- A. The voices are telling me to kill the next person I see.
- B. The fire is burning my skin away right now.
- C. The snakes on the wall are going to eat me.
- D. The nurse at night is trying to poison me with pills.
Correct answer: D
Rationale: The correct answer is D. Believing that the nurse is trying to poison him with pills is a clear indication of delusional paranoia, a common symptom in paranoid schizophrenia. Choices A, B, and C do not directly relate to paranoid delusions and are more indicative of hallucinations or other forms of delusions not specific to paranoia.
2. A client with schizophrenia is experiencing auditory hallucinations. What is the most appropriate nursing intervention?
- A. Encourage the client to focus on reality-based activities.
- B. Tell the client that the voices are not real.
- C. Ask the client to describe the voices he hears.
- D. Encourage the client to interact with others who are not experiencing hallucinations.
Correct answer: A
Rationale: The most appropriate nursing intervention for a client with schizophrenia experiencing auditory hallucinations is to encourage the client to focus on reality-based activities. This intervention helps redirect their attention away from hallucinations, promoting engagement with the environment. Choice B is incorrect as telling the client that the voices are not real may invalidate their experiences and worsen the therapeutic relationship. Choice C may increase the client's distress by focusing on the hallucinations. Choice D might not be helpful as interacting with others who are not experiencing hallucinations may not address the client's current needs.
3. A male client is admitted to the psychiatric unit with a medical diagnosis of paranoid schizophrenia. During the admission procedure, the client looks up and states, 'No, it's not MY fault. You can't blame me. I didn't kill him, you did.' What action is best for the nurse to take?
- A. Reassure the client by telling him that his fear of the admission procedure is to be expected.
- B. Tell the client that no one is accusing him of murder and remind him that the hospital is a safe place.
- C. Assess the content of the hallucinations by asking the client what he is hearing.
- D. Ignore the behavior and make no response at all to his delusional statements.
Correct answer: C
Rationale: The correct action for the nurse to take in this situation is to assess the content of the hallucinations by asking the client what he is hearing (C). Further assessment is needed to understand the nature of the client's delusions and hallucinations. Choice A is incorrect as it focuses on reassuring the client about his fear, which is not addressing the underlying issue of the delusional statement. Choice B is incorrect as it argues with the client's delusion and offers false reassurance, which is not therapeutic. Choice D is incorrect as ignoring the behavior and making no response disregards the client's needs for assessment and support.
4. Within several days of hospitalization, a client is repeatedly washing the top of the same table. Which initial intervention is best for the nurse to implement to help the client cope with anxiety related to this behavior?
- A. Administer a prescribed PRN antianxiety medication.
- B. Assist the client in identifying stimuli that precipitate the ritualistic activity.
- C. Allow time for the ritualistic behavior, then redirect the client to other activities.
- D. Teach the client relaxation and thought-stopping techniques.
Correct answer: C
Rationale: Initially, the nurse should allow time for the ritualistic behavior (C) to prevent anxiety. Administering an antianxiety medication (A) may help reduce the client's anxiety temporarily but will not address the underlying issue of ineffective coping mechanisms leading to the behavior. While assisting the client in identifying triggers (B) is important for long-term therapy, the immediate focus should be on managing the behavior. Teaching relaxation and thought-stopping techniques (D) is beneficial but might be more effective once the client is more stable and receptive to learning new coping strategies.
5. Which diet selection by a client who is depressed and taking the MAO inhibitor tranylcypromine sulfate (Parnate) indicates to the nurse that the client understands the dietary restrictions imposed by this medication regimen?
- A. Hamburger, French fries, and chocolate milkshake.
- B. Liver and onions, broccoli, and decaffeinated coffee.
- C. Pepperoni and cheese pizza, tossed salad, and a soft drink.
- D. Roast beef, baked potato with butter, and iced tea.
Correct answer: D
Rationale: Roast beef, baked potato with butter, and iced tea are safe choices as they do not contain tyramine, which must be avoided with MAO inhibitors like Parnate. Tyramine-rich foods like aged cheeses, certain meats, and fermented products can cause a hypertensive crisis when combined with MAO inhibitors. Choices A, B, and C contain foods high in tyramine and are not recommended for individuals taking MAO inhibitors.
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