HESI Mental Health 2023

HESI LPN

1. A nurse is assessing a client with generalized anxiety disorder (GAD) who reports difficulty concentrating and feeling restless. What is the most appropriate nursing intervention?

A. Encourage the client to avoid caffeine.
B. Suggest the client take up a new hobby.
C. Teach the client deep breathing exercises.
D. Refer the client to group therapy.

Correct answer: C

Rationale: Teaching deep breathing exercises is the most appropriate intervention for a client with generalized anxiety disorder (GAD) experiencing difficulty concentrating and restlessness. Deep breathing exercises are a proven technique to help manage anxiety symptoms, promote relaxation, and improve concentration. Encouraging the client to avoid caffeine (Choice A) may be beneficial, but it is not the most direct intervention for the reported symptoms. Suggesting the client take up a new hobby (Choice B) may be helpful for overall well-being but does not directly address the immediate symptoms. Referring the client to group therapy (Choice D) may be beneficial in the long term, but teaching deep breathing exercises is more immediate and can be easily implemented by the client in various settings.

2. On admission to a residential care facility, an elderly female client tells the nurse that she enjoys cooking, quilting, and watching television. Twenty-four hours after admission, the nurse notes that the client is withdrawn and isolated. It is best for the nurse to encourage this client to become involved in which activity?

A. Clean the unit kitchen cabinets.
B. Participate in a group quilting project.
C. Watch television in the activity room.
D. Bake a cake for a resident's birthday.

Correct answer: B

Rationale: Peer interaction in a group activity (B) such as participating in a group quilting project will help to prevent social isolation and withdrawal. This will provide the elderly client with an opportunity to engage with others, share experiences, and feel a sense of belonging. Choices (A, C, and D) are activities that can be accomplished alone, without peer interaction, which may not effectively address the client's feelings of withdrawal and isolation.

3. What is the priority intervention for a client with major depressive disorder admitted to the psychiatric unit with suicidal ideation?

A. Conduct a thorough suicide risk assessment.
B. Encourage the client to verbalize their feelings.
C. Provide the client with positive affirmations.
D. Refer the client to group therapy.

Correct answer: A

Rationale: The correct answer is to conduct a thorough suicide risk assessment. When a client with major depressive disorder presents with suicidal ideation, the priority is to assess the level of risk to ensure the client's safety. This assessment helps determine the appropriate interventions, level of care, and monitoring needed. Encouraging the client to verbalize their feelings (choice B) is important, but not the priority when immediate safety is a concern. Providing positive affirmations (choice C) and referring the client to group therapy (choice D) may be beneficial interventions later on but do not address the immediate risk of harm to the client.

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 female client with major depression is prescribed fluoxetine (Prozac). She reports experiencing increased energy but still feels sad and hopeless. What is the nurse's best response?

A. ''These feelings are normal and will pass with time.''
B. ''Increased energy can sometimes lead to increased risk for self-harm.''
C. ''The medication needs more time to be effective.''
D. ''Let's talk about the things that make you feel this way.''

Correct answer: B

Rationale: The correct answer is B. Increased energy without improvement in mood can increase the risk of self-harm in clients with depression. It is crucial for the nurse to recognize this potential risk and closely monitor the client for any signs of self-harm. Choice A is incorrect because dismissing the client's persistent feelings of sadness and hopelessness as normal may invalidate her experiences. Choice C is incorrect as fluoxetine (Prozac) typically starts showing effectiveness within a few weeks, so further delay is concerning. Choice D is incorrect because while discussing the client's feelings is important, the immediate focus should be on addressing the potential risk of self-harm associated with increased energy.