HESI Mental Health 2023

HESI LPN

1. A client with schizophrenia is experiencing delusions. What is the most appropriate nursing intervention?

A. Encourage the client to explore the delusions in depth.
B. Tell the client that the delusions are not real.
C. Explore the underlying meaning of the delusions.
D. Distract the client from the delusions and focus on reality.

Correct answer: D

Rationale: The most appropriate nursing intervention for a client with schizophrenia experiencing delusions is to distract the client from the delusions and focus on reality. Encouraging the client to explore the delusions in depth (Choice A) may worsen the delusions. Telling the client that the delusions are not real (Choice B) can lead to confrontation and disbelief. Exploring the underlying meaning of the delusions (Choice C) may not be effective during acute episodes of delusions; hence, distracting the client and refocusing on reality is the most suitable intervention.

2. A client with obsessive-compulsive disorder (OCD) spends several hours a day arranging and rearranging items in their room. What is the most therapeutic nursing intervention?

A. Distract the client with another activity.
B. Allow the client to continue the behavior.
C. Set a time limit for the behavior.
D. Encourage the client to verbalize their feelings.

Correct answer: D

Rationale: Encouraging the client to verbalize their feelings is the most therapeutic intervention for a client with OCD spending excessive time on compulsive behaviors. By expressing their feelings, the client can explore the underlying anxiety that drives the compulsion. This intervention also provides an opportunity for the nurse to offer support and help the client develop coping strategies.\n Choice A, distracting the client with another activity, may provide temporary relief but does not address the root cause of the behavior.\n Choice B, allowing the client to continue the behavior, does not promote therapeutic progress and may perpetuate the compulsion.\n Choice C, setting a time limit for the behavior, may create additional stress for the client and does not address the underlying emotional issues associated with OCD.

3. At a support meeting of parents of a teenager with polysubstance dependency, a parent states, 'Each time my son tries to quit taking drugs, he gets so depressed that I'm afraid he will commit suicide.' The nurse's response should be based on which information?

A. Addiction is a chronic, incurable disease.
B. Tolerance to the effects of drugs causes feelings of depression.
C. Feelings of depression frequently lead to drug abuse and addiction.
D. Careful monitoring should be provided during withdrawal from the drugs.

Correct answer: C

Rationale: The correct response in this situation should focus on the connection between feelings of depression and drug abuse. Choice A is incorrect because addiction is treatable, not incurable. Choice B is incorrect as tolerance does not directly cause depression. Choice D is not the best response as the parent's concern is about the son's depression leading to suicidal thoughts, not just the withdrawal process.

4. An adult male client who was admitted to the mental health unit yesterday tells the nurse that microchips were planted in his head for military surveillance of his every move. Which response is best for the nurse to provide?

A. You are in the hospital, and I am the nurse caring for you
B. It must be difficult for you to control your anxious feelings
C. Go to occupational therapy and start a project
D. You are not in a war area now; this is the United States

Correct answer: C

Rationale: Delusions often generate fear and isolation, so the nurse should help the client participate in activities that avoid focusing on the false belief and encourage interaction with others.

5. 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.