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HESI Mental Health
1. A client with borderline personality disorder is admitted to the psychiatric unit after a suicide attempt. The client frequently expresses feelings of emptiness and fears of abandonment. What is the most therapeutic nursing approach for this client?
- A. Encourage the client to participate in all group activities.
- B. Set clear and consistent boundaries while providing empathy.
- C. Reassure the client that the staff will not abandon them.
- D. Explore the client's past relationships in depth.
Correct answer: B
Rationale: The most therapeutic nursing approach for a client with borderline personality disorder, who frequently expresses feelings of emptiness and fears of abandonment, is to set clear and consistent boundaries while providing empathy. This approach helps manage the client's fear of abandonment and feelings of emptiness, which are common in borderline personality disorder. Option A may overwhelm the client in a group setting without addressing their specific needs. Option C, while well-intentioned, may not fully address the underlying issues and may create dependency. Option D delves into the client's past relationships, which may be inappropriate and trigger emotional distress in a vulnerable client.
2. When developing a plan of care for a client in the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing diagnosis has the highest priority?
- A. Risk for injury.
- B. Ineffective coping mechanisms.
- C. Alteration in comfort.
- D. Ineffective breathing patterns.
Correct answer: D
Rationale: When a client aspirates a caustic material, the priority nursing diagnosis should focus on addressing physiological concerns, particularly related to breathing patterns. Aspiration of caustic material can lead to airway compromise, respiratory distress, and potential lung damage. Therefore, monitoring and addressing ineffective breathing patterns are crucial for ensuring the client's immediate safety and well-being. Choices A, B, and C are important considerations in psychiatric care but are secondary to the critical physiological issue of ineffective breathing patterns in this scenario.
3. A 72-year-old female client is admitted to the psychiatric unit with a diagnosis of major depression. Which statement by the client should be of greatest concern to the nurse and require further assessment?
- A. "I will die if my cat dies."
- B. "I don't feel like eating this morning."
- C. "I just went to my friend's funeral."
- D. "Don't you have more important things to do?"
Correct answer: A
Rationale: Sometimes a client will use an analogy to describe themselves, and (A) would be an indication for conducting a suicide assessment. (B) could have a variety of etiologies, and while further assessment is indicated, this statement does not indicate potential suicide. The normal grief process differs from depression, and at this client's age, peer/cohort deaths are more frequent, so (C) would be within normal limits. (D) is an expression of low self-esteem typical of depression. Choices (B), (C), and (D) are examples of decreased energy and mood levels which would negate suicide ideation at this time.
4. A female client with schizophrenia tells the nurse that she believes her brain is controlled by the CIA. The nurse recognizes this as which type of delusion?
- A. Somatic delusion
- B. Paranoid delusion
- C. Persecutory delusion
- D. Grandiose delusion
Correct answer: C
Rationale: The correct answer is C: Persecutory delusion. Persecutory delusions involve beliefs of being conspired against, watched, or harassed by others, which is a common symptom in schizophrenia. In this scenario, the client's belief that her brain is controlled by the CIA aligns with persecutory delusions as she feels targeted or manipulated by an external entity. Choices A, B, and D are incorrect. Somatic delusions involve false beliefs about one's body functions or sensations, paranoid delusions involve irrational suspicions and mistrust of others, and grandiose delusions involve exaggerated beliefs of one's importance or abilities.
5. A male client is admitted to a mental health unit on Friday afternoon and is very upset on Sunday because he has not had the opportunity to talk with the healthcare provider. Which response is best for the nurse to provide this client?
- A. Let me call and leave a message for your healthcare provider.
- B. The healthcare provider should be here on Monday morning.
- C. How can I help answer your questions?
- D. What concerns do you have at this time?
Correct answer: A
Rationale: It is best for the nurse to call the healthcare provider (A) because clients have the right to information about their treatment. Suggesting that the healthcare provider will be available the following day (B) does not provide immediate reassurance to the client. While offering to help answer questions (C) and inquiring about concerns (D) are supportive approaches, contacting the healthcare provider is the most appropriate action to address the client's immediate need for communication with their healthcare provider.
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