HESI LPN
HESI Mental Health 2023
1. 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.
2. A 38-year-old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her, she refuses to eat and tells the nurse, 'I know you are trying to poison me with that food.' Which response would be most appropriate for the nurse to make?
- A. 'I'll leave your tray here. I am available if you need anything else.'
- B. 'You're not being poisoned. Why do you think someone is trying to poison you?'
- C. 'No one on this unit has ever died from poisoning. You're safe here.'
- D. 'I will talk to your healthcare provider about the possibility of changing your diet.'
Correct answer: A
Rationale: Choice (A) offers support without confrontation, allowing the client to feel safe and respected. Choices (B) and (C) directly challenge the client's delusion, which can increase anxiety and distrust. Choice (D) focuses on a non-essential issue and does not address the client's immediate emotional needs.
3. The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. What information should the nurse explore in depth with the client based on this screening tool?
- A. Cancer screening results, anger, gastritis, daily alcohol intake.
- B. Efforts to cut down, annoyance with questions, guilt, drinking as an 'Eye-opener.'
- C. Consumption, liver enzyme, gastrointestinal complaints and bleeding.
- D. Minimizes drinking, frequently misses family events, guilt about drinking, amount of daily intake.
Correct answer: B
Rationale: The CAGE questionnaire is used to identify problematic drinking behaviors. Choice B is correct because it includes key aspects that the nurse should explore further with the client. 'Efforts to cut down' can indicate acknowledgment of excessive drinking, 'guilt' reflects emotional distress related to drinking, and 'drinking as an 'Eye-opener'' suggests potential dependency. Choices A, C, and D are incorrect as they do not directly address the essential elements assessed by the CAGE questionnaire and may not provide relevant information for further evaluation of the client's drinking habits.
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 is taking a history for a female client who is requesting a routine female exam. Which assessment finding requires follow-up?
- A. Menstruation onset at age 9.
- B. Contraceptive method includes condoms only.
- C. Menstrual cycle occurs every 35 days.
- D. 'Black-out' after one drink last night on a date.
Correct answer: D
Rationale: The correct answer is D. Experiencing a 'black-out' after consuming only one drink is highly unusual and may indicate the client was drugged, necessitating immediate follow-up. Menstruation onset at age 9 and a menstrual cycle occurring every 35 days, although on the outer ranges of 'average,' are within acceptable norms. Relying solely on condoms as a contraceptive method increases the risk of conception.
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