HESI Mental Health

HESI LPN

1. A male client with delirium becomes disoriented and confused in his room at night. The best initial nursing intervention is to:

A. Move the client next to the nurse's station
B. Use an indirect light source and turn off the television
C. Keep the television and a soft light on during the night
D. Play soft music during the night, and maintain a well-lit room

Correct answer: B

Rationale: The best initial nursing intervention for a male client with delirium who becomes disoriented and confused in his room at night is to use an indirect light source and turn off the television. This approach helps to reduce stimulation and confusion, aiding in the client's orientation and comfort. Moving the client next to the nurse's station (Choice A) may not address the root cause of disorientation and could disrupt the client's routine. Keeping the television and a soft light on (Choice C) may further contribute to the client's confusion. Playing soft music and maintaining a well-lit room (Choice D) may not be as effective in reducing stimulation and promoting orientation as using an indirect light source and turning off the television.

2. A 52-year-old male client in the intensive care unit who has been oriented suddenly becomes disoriented and fearful. Assessment of vital signs and other physical parameters reveal no significant change, and the nurse formulates the diagnosis, 'Confusion related to ICU psychosis.' Which intervention would be best to implement?

A. Move all machines away from the client's immediate area.
B. Attempt to allay the client's fears by explaining the etiology of his condition.
C. Cluster care so that brief periods of rest can be scheduled during the day.
D. Extend visitation times for family and friends.

Correct answer: C

Rationale: In critical care environments, stressors can lead to isolation and confusion. Providing the client with scheduled rest periods (C) can help alleviate these symptoms. Moving all machines away (A) is impractical as they are often essential. Explaining the condition (B) may not be effective during acute confusion. Extending visitation times (D) can be overwhelming for the client in the ICU.

3. 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.

4. A client with schizophrenia is being discharged with a prescription for risperidone (Risperdal). What is the most important instruction for the nurse to provide?

A. Stop taking the medication if you start feeling better.
B. Be aware of the potential for weight gain with this medication.
C. Report any unusual muscle movements immediately.
D. You can drive as soon as you feel ready.

Correct answer: C

Rationale: The correct answer is C: "Report any unusual muscle movements immediately." Unusual muscle movements may indicate extrapyramidal symptoms (EPS) or tardive dyskinesia, which are serious side effects of antipsychotic medications like risperidone. It is crucial to address these symptoms promptly to prevent long-term effects. Choice A is incorrect because stopping the medication suddenly can be dangerous and should only be done under medical supervision. Choice B, while important, is not the most critical instruction in this scenario. Choice D is also incorrect as the ability to drive may be affected by the medication and should be discussed with a healthcare provider.

5. A male client with alcohol use disorder is admitted for detoxification. The nurse knows that which symptom is a sign of severe alcohol withdrawal?

A. Bradycardia
B. Seizures
C. Hyperglycemia
D. Constipation

Correct answer: B

Rationale: Seizures are a sign of severe alcohol withdrawal and can be life-threatening, requiring immediate medical attention. Bradycardia, hyperglycemia, and constipation are not typically associated with severe alcohol withdrawal. Bradycardia is more commonly seen in opioid withdrawal, hyperglycemia could be due to other reasons like uncontrolled diabetes, and constipation is not a typical symptom of severe alcohol withdrawal.