HESI LPN
HESI Mental Health
1. A client with a diagnosis of schizophrenia is experiencing auditory hallucinations. What is the most appropriate nursing intervention?
- A. Ask the client to describe the voices and what they are saying.
- B. Tell the client that the voices are not real.
- C. Encourage the client to engage in reality-based activities.
- D. Ask the client to focus on positive thoughts instead of the voices.
Correct answer: C
Rationale: The most appropriate nursing intervention for a client with schizophrenia experiencing auditory hallucinations is to encourage them to engage in reality-based activities. This intervention helps manage auditory hallucinations by redirecting the client's focus away from the hallucinations. Choice A is not recommended as it may exacerbate the hallucinations or distress the client. Choice B is incorrect because denying the reality of the voices can invalidate the client's experiences. Choice D, asking the client to focus on positive thoughts, may not be effective in addressing the auditory hallucinations directly.
2. 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.
3. Over a period of several weeks, one male participant of a socialization group at a community day care center for the elderly monopolizes most of the group's time and interrupts others when they are talking. What is the best action for the nurse to take in this situation?
- A. Talk to the participant outside the group about his behavior during group meetings.
- B. Remind the participant to allow others in the group a chance to talk.
- C. Allow the group to handle the problem.
- D. Ask the participant to join another group.
Correct answer: C
Rationale: Allowing the group to handle the situation is the best action as it promotes group dynamics and empowerment, especially since the group is in the working phase. Talking to the participant individually (A) might be seen as manipulative. Reminding the participant (B) can come across as dictatorial and may not address the underlying issue. Asking the participant to join another group (D) does not address the problem at hand and avoids the opportunity for growth and conflict resolution within the current group.
4. An adult female client tells the nurse that though she is afraid her abusive boyfriend might one day kill her, she keeps hoping that he will change. What action should the nurse take first?
- A. Discuss treatment options for abusive partners.
- B. Explore the client's readiness to discuss the situation.
- C. Determine the frequency and type of client's abuse.
- D. Report the finding to the police department.
Correct answer: B
Rationale: Exploring the client's readiness to discuss the situation is the correct first step. It allows the nurse to assess the client's emotional state, willingness to seek help, and readiness to address the abusive relationship. This approach helps build trust and rapport with the client, paving the way for further interventions. Discussing treatment options for abusive partners (Choice A) may be premature and not well-received if the client is not ready to address the situation. Determining the frequency and type of abuse (Choice C) is important but not the immediate priority compared to assessing the client's readiness to talk. Reporting the finding to the police (Choice D) should be done if there is an immediate threat to the client's safety, but exploring the client's readiness to discuss the situation should be the initial step to provide support and intervention.
5. A 45-year-old female client is admitted to the psychiatric unit for evaluation. Her husband states that she has been reluctant to leave home for the last six months. The client has not gone to work for a month and has been terminated from her job. She has not left the house since that time. This client is displaying symptoms of what condition?
- A. Claustrophobia
- B. Acrophobia
- C. Agoraphobia
- D. Post-traumatic stress disorder
Correct answer: C
Rationale: The correct answer is C: Agoraphobia. Agoraphobia is the fear of crowds or being in open places, often leading individuals to avoid situations where they feel trapped, insecure, or out of control. In the case described, the client's reluctance to leave home, avoidance of work, and isolation within the house are indicative of agoraphobia. Claustrophobia (A) is the fear of closed places, while acrophobia (B) is the fear of high places. Post-traumatic stress disorder (D) involves the development of anxiety symptoms following a traumatic event, characterized by terror, fear, and helplessness, and is different from a phobia.
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