HESI Mental Health Practice Questions

Correct Answer: C

Rationale: Taking a self-defense course that retaliates against the abuser with injury can escalate the level of violence and is not recommended in a safety plan for a victim of intimate partner violence. The correct strategies include establishing a code, having a bag ready, and planning an escape route, which enhance safety without increasing the risk of harm.

Correct Answer: B

Rationale: Assessing intake and output is crucial during the first 24 hours after admission for detoxification. This helps the nurse monitor the client's hydration status and kidney function as the body goes through withdrawal from heroin. Option A is incorrect because joining a support group is beneficial but may not be the priority in the initial phase of detoxification. Option C, monitoring for wheezing and apnea, is important but not the most critical intervention during the first 24 hours. Option D, limiting visitors to family members only, is not directly related to the immediate needs of assessing intake and output.

Correct Answer: A

Rationale: A shuffling gait and tremors may indicate extrapyramidal side effects (EPS) from risperidone. The nurse's priority action should be to administer an anticholinergic medication as it can help alleviate these symptoms associated with EPS. Documenting the findings and monitoring the client (Choice B) are important but addressing the immediate symptoms takes precedence. Assessing the client's blood glucose level (Choice C) is not directly related to the observed symptoms of shuffling gait and tremors. While notifying the healthcare provider (Choice D) is important, it is not the priority action when dealing with EPS symptoms.

Correct Answer: D

Rationale: The correct answer is to weigh the client daily at the same time. Daily weights are crucial in monitoring the client's nutritional status and guiding treatment for weight restoration in anorexia nervosa. Monitoring vital signs is important but weighing the client daily takes precedence in this situation. Encouraging group therapy and offering high-calorie snacks are important aspects of treatment but do not take priority over monitoring the client's weight.

Correct Answer: B

Rationale: The correct answer is B: 'Violent behavior.' When a client has overdosed on PCP, the nurse should be particularly cautious about the manifestation of violent behavior. PCP overdose can lead to aggressive and unpredictable actions, posing a significant risk to both the client and healthcare providers. Visual hallucinations (choice A), bizarre behavior (choice C), and loud screaming (choice D) can also occur with PCP overdose, but the primary concern should be the potential for violent behavior, making it the most critical behavior to monitor and manage.