HESI LPN
HESI Mental Health 2023
1. 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.
2. 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.
3. A young adult male client, diagnosed with paranoid schizophrenia, believes that the world is trying to poison him. What intervention should the nurse include in this client's plan of care?
- A. Remind the client that his suspicions are not true.
- B. Ask one nurse to spend time with the client daily.
- C. Encourage the client to participate in group activities.
- D. Assign the client to a room closest to the activity room.
Correct answer: B
Rationale: A client with paranoid schizophrenia has difficulty with trust and developing a trusting relationship with one nurse (B) is likely to be therapeutic for this client. Choice (A) is argumentative and may increase the client's resistance. Choice (C) might be too overwhelming and anxiety-provoking for the client. Choice (D) could increase the client's stress and anxiety, which are counterproductive in managing paranoid ideations.
4. 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.
5. 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.
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