HESI Mental Health 2023

HESI LPN

1. 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.

2. A nurse is caring for a client with depression who has been prescribed sertraline (Zoloft). The client reports experiencing nausea. What is the nurse's best response?

A. "You should stop taking the medication immediately."
B. "Nausea is a common side effect and usually decreases over time."
C. "Try taking the medication with food to reduce nausea."
D. "I will inform the healthcare provider to change your medication."

Correct answer: B

Rationale: The correct answer is B: "Nausea is a common side effect of sertraline, and clients should be reassured that it usually decreases as their body adjusts to the medication." Choice A is incorrect because abruptly stopping the medication without consulting a healthcare provider can be harmful. Choice C is a good suggestion to reduce nausea by taking the medication with food but does not address the temporary nature of the side effect. Choice D is unnecessary at this point since nausea is a common side effect that may improve with time.

3. 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.

4. What is the most appropriate nursing intervention for a client with obsessive-compulsive disorder (OCD) who is constantly washing her hands?

A. Allow the client to continue washing her hands.
B. Set limits on the time spent washing her hands.
C. Encourage the client to wash her hands less frequently.
D. Assist the client in finding alternative ways to reduce anxiety.

Correct answer: D

Rationale: Assisting the client in finding alternative ways to reduce anxiety is the most appropriate intervention for a client with OCD who is constantly washing her hands. This approach helps address the underlying cause of the compulsive behavior by focusing on reducing anxiety rather than reinforcing the behavior. Allowing the client to continue washing her hands (choice A) would not address the root of the issue and may perpetuate the behavior. Setting limits on the time spent washing hands (choice B) may cause distress to the client and does not address the core problem. Encouraging the client to wash her hands less frequently (choice C) does not provide effective coping strategies for managing anxiety associated with OCD.

5. What is the most therapeutic nursing response for a client with borderline personality disorder who engages in self-mutilating behavior?

A. Encourage the client to stop hurting themselves.
B. Discuss what the client was feeling before self-harming.
C. Inform the client that the behavior will be reported to their doctor.
D. Ask the client why they hurt themselves.

Correct answer: B

Rationale: The most therapeutic nursing response for a client with borderline personality disorder engaging in self-mutilating behavior is to discuss what the client was feeling before self-harming. This approach helps in exploring the underlying triggers and emotions that lead to self-harm. Option A is directive and may come across as judgmental rather than empathetic. Option C can lead to feelings of betrayal and breach of trust. Option D is a closed-ended question that may not facilitate open communication or exploration of emotions.