HESI LPN
HESI Mental Health 2023
1. Which statement best demonstrates the nurse's role in ensuring that each client's rights are respected?
- A. Autonomy is a fundamental right for each client.
- B. Client rights are guaranteed by both state and federal laws.
- C. Being respectful and concerned will ensure attentiveness to clients' rights.
- D. Regardless of the client's condition, nurses must respect client rights.
Correct answer: C
Rationale: The statement 'Being respectful and concerned will ensure attentiveness to clients' rights' best demonstrates the nurse's role in ensuring that each client's rights are respected. This choice emphasizes the importance of being attentive and considerate towards clients to uphold their rights. Choice A is too general and lacks the direct connection to the nurse's role. Choice B highlights the legal aspect but does not specifically address the nurse's role. Choice D, although true, is not as comprehensive as choice C in describing the nurse's active role in respecting client rights.
2. A male client with borderline personality disorder is manipulative and consistently attempts to violate unit rules. What is the best approach for the nurse to take?
- A. Enforce unit rules consistently with all clients.
- B. Ignore the manipulative behaviors to avoid confrontation.
- C. Provide the client with special privileges to avoid conflict.
- D. Confront the client directly about his behavior.
Correct answer: A
Rationale: The correct approach for the nurse to take when dealing with a male client with borderline personality disorder who is manipulative and consistently attempts to violate unit rules is to enforce unit rules consistently with all clients. By maintaining consistency in enforcing rules, the nurse establishes clear boundaries and provides structure, which are essential for managing manipulative behavior in clients with borderline personality disorder. Ignoring the manipulative behaviors (Choice B) may lead to the reinforcement of negative behaviors. Providing the client with special privileges (Choice C) can enable further manipulation and is not recommended. Confronting the client directly about his behavior (Choice D) may escalate the situation and is less effective than consistent rule enforcement.
3. A male client is admitted to the mental health unit because he was feeling depressed about the loss of his wife and job. The client has a history of alcohol dependency and admits that he was drinking alcohol 12 hours ago. Vital signs are: temperature, 100 F, pulse 100, and BP 142/100. The nurse plans to give the client lorazepam (Ativan) based on which priority nursing diagnosis?
- A. Risk for injury related to suicidal ideation.
- B. Risk for injury related to alcohol detoxification.
- C. Knowledge deficit related to ineffective coping.
- D. Health-seeking behaviors related to personal crisis.
Correct answer: B
Rationale: The most important nursing diagnosis is related to alcohol detoxification (B) because the client has elevated vital signs, a sign of alcohol detoxification. Giving lorazepam (Ativan) to address the elevated vital signs due to alcohol withdrawal is a priority. Addressing the risk for injury related to suicidal ideation (A) should come after stabilizing the client's physiological state. Both (C) and (D) can be addressed once immediate safety needs are met, but the priority is managing the alcohol detoxification to prevent potential complications.
4. 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.
5. The nurse should hold the next scheduled dose of a client's haloperidol (Haldol) based on which assessment finding(s)?
- A. Dizziness when standing.
- B. Shuffling gait and hand tremors.
- C. Urinary retention.
- D. Fever of 102°F.
Correct answer: D
Rationale: A fever (D) may indicate neuroleptic malignant syndrome (NMS), a potentially fatal complication of antipsychotics. The healthcare provider should be contacted before administering the next dose of Haldol. Dizziness when standing (A), shuffling gait and hand tremors (B), and urinary retention (C) are all adverse effects of Haldol that, while concerning, do not pose immediate life-threatening risks compared to the potential severity of NMS indicated by a fever.
Similar Questions
Access More Features
HESI LPN Basic
$69.99/ 30 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $69.99
HESI LPN Premium
$149.99/ 90 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $149.99