HESI Mental Health 2023

HESI LPN

1. The nurse observes a female client with schizophrenia watching the news on TV. She begins to laugh softly and says, 'Yes, my love, I'll do it.' When the nurse questions the client about her comment, she states, 'The news commentator is my lover, and he speaks to me each evening. Only I can understand what he says.' What is the best response for the nurse to make?

A. What do you believe the news commentator said to you?
B. Let's watch the news on a different television channel.
C. Does the news commentator have plans to harm you or others?
D. The news commentator is not talking to you.

Correct answer: A

Rationale: The correct response for the nurse is to ask the client, 'What do you believe the news commentator said to you?' This is important to determine the content of the auditory hallucination and understand the client's perception. Choice B is incorrect as changing the TV channel does not address the underlying issue. Choice C is incorrect as it introduces a paranoid idea that the news commentator may have harmful intentions, which is not supported by the scenario. Choice D is incorrect as it dismisses the client's belief without exploring or validating her experience.

2. A female client with depression attends a group and states that she sometimes misses her medication appointments because she feels very anxious about riding the bus. Which statement is the nurse's best response?

A. Can your case manager take you to your appointments?
B. Take your medication for anxiety before you ride the bus.
C. Let's talk about what happens when you feel very anxious.
D. What are some ways that you can cope with your anxiety?

Correct answer: D

Rationale: Encouraging the client to discuss coping mechanisms for anxiety is a supportive approach that empowers the client to manage their symptoms. Choice A may not address the client's self-management and coping skills. Choice B suggests using anxiety medication before riding the bus, which may not be the most appropriate solution. Choice C acknowledges the anxiety but does not actively involve the client in finding solutions, unlike Choice D which promotes client empowerment and self-efficacy.

3. 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.

4. An 86-year-old female client with Alzheimer's disease is wandering the busy halls of the extended care facility and asks the nurse, "Where should I stand for the parade?" Which response is best for the LPN/LVN to provide?

A. Anywhere you want to stand as long as you do not get hurt by those in the parade.
B. You are confused because of all the activity in the hall. There is no parade.
C. Let us go back to the activity room and see what is going on in there.
D. Remember I told you that this is a nursing home and I am your nurse.

Correct answer: C

Rationale: Redirecting the client to a less confusing environment can help reduce anxiety and reorient her to reality.

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.