HESI LPN
HESI Mental Health
1. Which information should the LPN/LVN exclude in the nursing plan of care for a client with obsessive-compulsive disorder (OCD)?
- A. The medical diagnosis of the client
- B. Individualized goals and objectives
- C. Attendance at group therapy sessions
- D. Self-care measures to improve hygiene
Correct answer: A
Rationale: The correct answer is A because including the medical diagnosis of the client in the nursing plan is redundant as the healthcare team is already aware of the diagnosis. The nursing plan of care for a client with OCD should focus on individualized goals, objectives, attendance at group therapy sessions, and self-care measures to improve hygiene. These components directly contribute to addressing the client's needs and promoting recovery. Therefore, the medical diagnosis does not need to be included in the nursing plan as it does not actively guide the day-to-day care and interventions for the client.
2. The occupational health nurse is working with a female employee who was just notified that her child was involved in a MVA and taken to the hospital. The employee states, 'I can't believe this. What should I do?' Which response is best for the nurse to provide in this crisis?
- A. Tell me what you think should happen.
- B. How serious was the collision?
- C. What do you think you should do?
- D. Call for transportation to the hospital.
Correct answer: D
Rationale: Providing immediate practical support, such as arranging transportation to the hospital, is the best response in this crisis situation. It helps the employee to take immediate action and supports her in a highly stressful moment. Choice A focuses on the employee's thoughts rather than providing immediate aid. Choice B is not a priority as the severity can be addressed later. Choice C puts the decision-making burden on the employee at a time of distress, which is not ideal. Therefore, choice D is the most appropriate response in this situation.
3. A client's medication sheet contains a prescription for sertraline (Zoloft). To ensure safe administration of the medication, a nurse would administer the dose:
- A. On an empty stomach
- B. At the same time each evening
- C. Evenly spaced around the clock
- D. As needed when the client complains of depression
Correct answer: B
Rationale: The correct answer is B: 'At the same time each evening.' Sertraline should be administered at the same time each evening to maintain steady drug levels and effectiveness. Choice A is incorrect because sertraline can be taken with or without food. Choice C is incorrect as sertraline does not need to be spaced around the clock. Choice D is incorrect as sertraline is a scheduled medication and should not be taken on an as-needed basis for complaints of depression.
4. 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.
5. 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.
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