HESI Mental Health

HESI LPN

1. 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.

2. A female client in an acute care facility has been on antipsychotic medications for the past three days. Her psychotic behaviors have decreased and she has had no adverse reactions. On the fourth day, the client's blood pressure increases, she becomes pale and febrile, and demonstrates muscular rigidity. What action should the nurse initiate?

A. Place the client on seizure precautions and monitor her frequently.
B. Take the client's vital signs and notify the physician immediately.
C. Describe the symptoms to the charge nurse and document them in the client's record.
D. No action is required at this time as these are known side effects of her medications.

Correct answer: B

Rationale: The correct action for the nurse to initiate is to take the client's vital signs and notify the physician immediately. These symptoms may indicate neuroleptic malignant syndrome, a rare but life-threatening reaction to antipsychotic medications, requiring immediate medical attention. Placing the client on seizure precautions and monitoring her frequently (Choice A) is not the most appropriate action in this situation. Describing the symptoms to the charge nurse and documenting them in the client's record (Choice C) delays prompt medical intervention. Choosing not to take any action (Choice D) is dangerous as the symptoms described suggest a serious condition that needs urgent evaluation and treatment.

3. A male client with alcohol dependence is admitted for detoxification. The nurse knows that which assessment finding is indicative of alcohol withdrawal?

A. Bradycardia
B. Hypotension
C. Tremors
D. Hyperglycemia

Correct answer: C

Rationale: Tremors are a common sign of alcohol withdrawal. The central nervous system becomes hyperexcitable due to the suppression caused by chronic alcohol intake. Tremors are a manifestation of this hyperexcitability and are a key indicator of alcohol withdrawal. Bradycardia and hypotension are more commonly associated with conditions like shock or severe dehydration rather than alcohol withdrawal. Hyperglycemia is not a typical finding in alcohol withdrawal; instead, hypoglycemia is more commonly seen due to the effects of alcohol on glucose metabolism.

4. 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.

5. 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.