HESI LPN
HESI Mental Health 2023
1. A client with schizophrenia is experiencing distressful thoughts secondary to paranoia. Which intervention(s) should the LPN/LVN include in the plan of care? Select one intervention that does not apply.
- A. Avoid laughing when near the client
- B. Whisper when communicating near the client
- C. Increase socialization of the client among peers
- D. Have the client sign a written release of information form
Correct answer: B
Rationale: The correct intervention for a client with schizophrenia experiencing distressful thoughts secondary to paranoia is to avoid laughing when near the client. This is important as laughter can be misinterpreted and exacerbate the client's paranoia. Whispering when communicating near the client is not an appropriate intervention as it may lead the client to think secretive or negative information is being shared about them, further fueling their paranoia. Increasing socialization among peers can help provide support and reduce feelings of isolation, while having the client sign a written release of information form is not directly related to managing paranoia and distressful thoughts.
2. The LPN/LVN is caring for a client who is experiencing alcohol withdrawal. Which intervention should the nurse implement first?
- A. Administer a PRN dose of lorazepam (Ativan).
- B. Monitor the client's vital signs.
- C. Place the client on seizure precautions.
- D. Encourage the client to express feelings about withdrawal.
Correct answer: B
Rationale: When caring for a client experiencing alcohol withdrawal, the first intervention the nurse should implement is to monitor the client's vital signs. Vital sign monitoring is crucial to assess for any potential complications such as hypertension, tachycardia, fever, or other signs of autonomic hyperactivity. Administering medication like lorazepam (Ativan) would come after assessing the vital signs to determine the need for pharmacological intervention. Placing the client on seizure precautions is important, but assessing vital signs takes precedence to ensure immediate safety. Encouraging the client to express feelings about withdrawal is a supportive intervention but does not address the immediate physiological risk associated with alcohol withdrawal.
3. The nurse is performing intake interviews at a psychiatric clinic. A female client with a known history of drug abuse reports that she had a heart attack four years ago. Use of which substance abuse places the client at the highest risk for myocardial infarction?
- A. Benzodiazepines
- B. Marijuana
- C. Methamphetamine
- D. Alcohol
Correct answer: C
Rationale: Methamphetamine use is strongly associated with cardiovascular risks, including myocardial infarction, due to its stimulant effects on the heart. Benzodiazepines (Choice A) are not typically associated with an increased risk of myocardial infarction. Marijuana (Choice B) is not commonly linked to heart attacks, though it can have other health effects. Alcohol (Choice D) abuse can lead to cardiovascular issues, but methamphetamine has a more direct and potent impact on the heart, making it the highest risk factor in this scenario.
4. A client with schizophrenia is experiencing delusions. What is the most appropriate nursing intervention?
- A. Encourage the client to explore the delusions in depth.
- B. Tell the client that the delusions are not real.
- C. Explore the underlying meaning of the delusions.
- D. Distract the client from the delusions and focus on reality.
Correct answer: D
Rationale: The most appropriate nursing intervention for a client with schizophrenia experiencing delusions is to distract the client from the delusions and focus on reality. Encouraging the client to explore the delusions in depth (Choice A) may worsen the delusions. Telling the client that the delusions are not real (Choice B) can lead to confrontation and disbelief. Exploring the underlying meaning of the delusions (Choice C) may not be effective during acute episodes of delusions; hence, distracting the client and refocusing on reality is the most suitable intervention.
5. 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.
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