HESI Mental Health 2023

HESI LPN

1. On admission to a residential care facility, an elderly female client tells the nurse that she enjoys cooking, quilting, and watching television. Twenty-four hours after admission, the nurse notes that the client is withdrawn and isolated. It is best for the nurse to encourage this client to become involved in which activity?

A. Clean the unit kitchen cabinets.
B. Participate in a group quilting project.
C. Watch television in the activity room.
D. Bake a cake for a resident's birthday.

Correct answer: B

Rationale: Peer interaction in a group activity (B) such as participating in a group quilting project will help to prevent social isolation and withdrawal. This will provide the elderly client with an opportunity to engage with others, share experiences, and feel a sense of belonging. Choices (A, C, and D) are activities that can be accomplished alone, without peer interaction, which may not effectively address the client's feelings of withdrawal and isolation.

2. An adult male client who was admitted to the mental health unit yesterday tells the nurse that microchips were planted in his head for military surveillance of his every move. Which response is best for the nurse to provide?

A. You are in the hospital, and I am the nurse caring for you
B. It must be difficult for you to control your anxious feelings
C. Go to occupational therapy and start a project
D. You are not in a war area now; this is the United States

Correct answer: C

Rationale: Delusions often generate fear and isolation, so the nurse should help the client participate in activities that avoid focusing on the false belief and encourage interaction with others.

3. A client with obsessive-compulsive disorder (OCD) spends several hours a day arranging and rearranging items in their room. What is the most therapeutic nursing intervention?

A. Distract the client with another activity.
B. Allow the client to continue the behavior.
C. Set a time limit for the behavior.
D. Encourage the client to verbalize their feelings.

Correct answer: D

Rationale: Encouraging the client to verbalize their feelings is the most therapeutic intervention for a client with OCD spending excessive time on compulsive behaviors. By expressing their feelings, the client can explore the underlying anxiety that drives the compulsion. This intervention also provides an opportunity for the nurse to offer support and help the client develop coping strategies.\n Choice A, distracting the client with another activity, may provide temporary relief but does not address the root cause of the behavior.\n Choice B, allowing the client to continue the behavior, does not promote therapeutic progress and may perpetuate the compulsion.\n Choice C, setting a time limit for the behavior, may create additional stress for the client and does not address the underlying emotional issues associated with OCD.

4. A teenaged male client is admitted to the postoperative unit following open reduction of a fractured femur which occurred when he fell down the stairs at a party. The nurse notices needle marks on the client's arms and plans to observe for narcotic withdrawal. Early signs of narcotic withdrawal include which assessment findings?

A. Vomiting, seizures, and loss of consciousness.
B. Depression, fatigue, and dizziness.
C. Hypotension, shallow respirations, and dilated pupils.
D. Agitation, sweating, and abdominal cramps.

Correct answer: D

Rationale: Agitation, sweating, and abdominal cramps are early signs of narcotic withdrawal. Vomiting, seizures, and loss of consciousness (Option A) are more indicative of severe withdrawal or overdose symptoms. Depression, fatigue, and dizziness (Option B) are not typically early signs of narcotic withdrawal. Hypotension, shallow respirations, and dilated pupils (Option C) are more associated with opioid overdose rather than withdrawal. Monitoring for agitation, sweating, and abdominal cramps is crucial for managing narcotic withdrawal symptoms effectively.

5. The nurse is caring for a client who received the first-time electroconvulsive therapy (ECT) a half hour ago. Which action should the nurse implement first?

A. Offer oral fluids.
B. Monitor vital signs.
C. Evaluate ECT effectiveness.
D. Encourage group participation.

Correct answer: B

Rationale: After a client receives electroconvulsive therapy (ECT), the nurse's priority should be to monitor vital signs. This is important to ensure the client's physical stability and detect any immediate complications post-procedure. Offering oral fluids, evaluating ECT effectiveness, and encouraging group participation are all important aspects of care but monitoring vital signs takes precedence in the immediate post-ECT period.