HESI LPN
HESI Mental Health 2023
1. A young adult male with a history of substance abuse is admitted to the psychiatric unit for detoxification. He is agitated, sweating, and reports seeing bugs crawling on the walls. What is the priority nursing intervention?
- A. Reassure the client that the bugs are not real.
- B. Administer the prescribed benzodiazepine.
- C. Place the client in a quiet, dark room.
- D. Encourage the client to express his feelings.
Correct answer: B
Rationale: The correct answer is to administer the prescribed benzodiazepine. This intervention helps manage the client's agitation and hallucinations, which are common symptoms during detoxification from substances. Reassuring the client that the bugs are not real (Choice A) may not be effective in addressing the underlying causes of the hallucinations. Placing the client in a quiet, dark room (Choice C) may help reduce sensory stimulation but does not directly address the client's symptoms. Encouraging the client to express his feelings (Choice D) is important for therapeutic communication but may not be the priority when the client is experiencing severe agitation and hallucinations.
2. A client with schizophrenia is admitted to the psychiatric care unit for aggressive behavior, auditory hallucinations, and potential for self-harm. The client has not been taking medications as prescribed and insists that the food has been poisoned and refuses to eat. What intervention should the RN implement?
- A. Assure the client that all food served in the hospital is safe to eat.
- B. Tell the client that irrational thinking is a symptom of schizophrenia.
- C. Obtain an order for a tube feeding for the client.
- D. Provide the client with food in unopened containers.
Correct answer: D
Rationale: The correct intervention is to provide the client with food in unopened containers. This approach can help alleviate the client's fear of poisoning and encourage eating. Choice A may not address the client's specific fear and may be perceived as dismissive. Choice B, while providing information about symptoms of schizophrenia, does not address the immediate issue of the client's refusal to eat due to the fear of poisoning. Choice C of obtaining an order for tube feeding is premature and invasive before exploring less restrictive options.
3. An elderly client was prescribed Ativan 1 mg three times a day to help calm her anxiety after her husband's death. The next day the client calls her daughter asking when she is picking her up to go to the graveside. The client says she has been walking up and down the driveway for the past hour waiting for her daughter. Noting the client's agitation, hyperactivity, and insistence, the daughter calls the nurse to report her mother's behavior. What should the nurse suspect?
- A. The client is manic and may need a sleeping pill
- B. The client is experiencing a medication interaction and should go to the ED
- C. The client is experiencing a paradoxical reaction to the Ativan and should stop the new medication immediately
- D. The client is overcome by grief and probably needs an antidepressant
Correct answer: C
Rationale: A paradoxical reaction to Ativan, where the drug causes opposite effects such as increased agitation and hyperactivity, should prompt immediate cessation of the medication. In this scenario, the client was prescribed Ativan to help calm her anxiety, but instead, she is displaying symptoms of increased agitation and hyperactivity, indicating a paradoxical reaction. Choice A is incorrect because the symptoms described do not align with mania. Choice B is incorrect as there is no mention of a medication interaction. Choice D is incorrect as the symptoms are more indicative of a paradoxical reaction rather than overwhelming grief.
4. A client with borderline personality disorder tells the nurse, 'You're the only one who understands me. The other nurses don't care about me.' Which response by the nurse is most appropriate?
- A. Why do you feel that way about the other nurses?
- B. The other nurses care about you too.
- C. I am here to help you just like the other nurses.
- D. Let's talk about why you feel this way.
Correct answer: C
Rationale: The most appropriate response is 'I am here to help you just like the other nurses' (C). This response sets boundaries and avoids reinforcing the client's splitting behavior, which is common in borderline personality disorder. Choices A and D may unintentionally reinforce the splitting by focusing on the negative perception of other nurses. Choice B might be perceived as dismissive because it contradicts the client's feelings of being understood only by the nurse.
5. A client in a long-term care facility who has multiple sclerosis is embarrassed about the need to use a wheelchair and the muscle spasms that are readily visible in her legs. Which approach is therapeutic in assisting the client to cope?
- A. Keep the client in her room as much as possible
- B. Assist the client with all activities of daily living
- C. Tell the client that many of the people in the facility have these same sorts of problems
- D. Encourage and praise perseverance in performing ADLs, and assist the client to dress and groom daily
Correct answer: D
Rationale: Encouraging and praising the client's perseverance in performing activities of daily living (ADLs) is therapeutic as it helps the client maintain a sense of normalcy and dignity, thus supporting their psychosocial well-being. This approach acknowledges the client's struggles while empowering them to maintain their independence and self-care. Choices A and C are incorrect as they do not address the client's emotional needs and may contribute to further isolation and distress. Choice B, while important, does not specifically address the client's feelings of embarrassment and the need for emotional support.
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