HESI Mental Health Practice Exam

Correct Answer: D

Rationale: The correct answer is to refer the client for a psychiatric evaluation. The client's statement indicating hearing voices telling them to hurt themselves is a serious concern and suggests a risk for self-harm. Referring the client for a psychiatric evaluation is crucial for further assessment and intervention by mental health professionals. Choice A is incorrect because ignoring the voices may not address the client's safety. Choice B is incorrect as it oversimplifies the situation and does not address the immediate risk. Choice C is not as comprehensive as referring for a psychiatric evaluation, which is necessary in this situation.

Correct Answer: A

Rationale: When a client is guarded, suspicious, and resistant to talking, it is important for the nurse to attempt to ask the client simple questions. Simple questions can help build rapport, establish trust, and create a non-threatening environment. This approach may ease the client into more detailed discussions while reducing feelings of suspicion. Postponing the interview may increase the client's anxiety and distrust, while asking another nurse to talk with the client may disrupt continuity of care and the establishment of a therapeutic relationship. Documenting the client's behavior is important for the client's medical record, but it should not be the first action taken in this situation.

Correct Answer: C

Rationale: Psychotic clients often experience delusions due to difficulties with trust and low self-esteem (C). In this case, the client's belief that someone is trying to poison him is likely a manifestation of his underlying issues with trust and self-worth. Building trust and promoting positive self-esteem are essential in caring for such clients. Choices A, B, and D are incorrect because delusions are not primarily related to early childhood experiences involving authority issues, anger about hospitalization, or phobic fear of food. These factors do not directly contribute to the development of delusions in psychotic clients.

Correct Answer: A

Rationale: Photosensitivity is a side effect of Prolixin, and a vacation in the Bahamas (with its tropical island climate) increases the client's risk of experiencing this side effect. Therefore, the client should be advised to avoid direct sun exposure. Choice A indicates a need for health teaching as the client plans to return from vacation in 18 days, which is earlier than the scheduled dose of Prolixin at 20 days after discharge. Choices B, C, and D demonstrate accurate knowledge. Choice B is important because alcohol can interact with Prolixin. Choice C is relevant as it mentions signs of agranulocytosis, a potential side effect of Prolixin. Choice D is correct as benztropine mesylate is used to prevent extrapyramidal symptoms associated with Prolixin.

Correct Answer: B

Rationale: Asking the client what the voices are saying is the most appropriate intervention as it helps the nurse assess the content of the hallucinations and the potential risk they may pose. Encouraging the client to ignore the voices (Choice A) may not address the underlying issue or provide valuable information for the nurse. Distracting the client with a new activity (Choice C) may temporarily divert attention but does not address the hallucinations. Telling the client that the voices are not real (Choice D) may invalidate the client's experience and can lead to distrust in the therapeutic relationship.