HESI LPN
HESI Mental Health 2023
1. A nurse is caring for a client who is experiencing withdrawal symptoms from opioid addiction. What is the priority nursing intervention?
- A. Monitor for signs of respiratory depression.
- B. Administer methadone as prescribed.
- C. Provide a calm and quiet environment.
- D. Encourage fluid intake to prevent dehydration.
Correct answer: A
Rationale: The correct answer is A: Monitor for signs of respiratory depression. During opioid withdrawal, the priority is to monitor the client for respiratory depression as it can be life-threatening. Respiratory depression is a serious concern during opioid withdrawal, and prompt recognition and intervention are crucial. Administering methadone as prescribed (Choice B) may be part of the treatment plan but is not the priority in this situation. Providing a calm and quiet environment (Choice C) and encouraging fluid intake to prevent dehydration (Choice D) are important aspects of care but do not take precedence over monitoring for respiratory depression.
2. 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.
3. A female victim of sexual assault is being seen in the crisis center. The client states that she still feels 'as though the rape just happened yesterday,' even though it has been a few months since the incident. The appropriate nursing response is which of the following?
- A. You need to try to be realistic. The rape did not just occur.
- B. It will take some time to get over these feelings about your rape.
- C. Tell me more about the incident that causes you to feel like the rape just occurred.
- D. What do you think you can do to alleviate some of your fears about being raped again?
Correct answer: C
Rationale: The correct response is to encourage the client to talk about the event that makes them feel as though the rape just occurred. This approach can help the client process their feelings and experiences, which is crucial in dealing with trauma. Choice A is dismissive and negates the client's feelings, which can be harmful. Choice B, although acknowledging the time needed to heal, does not actively address the client's current feelings. Choice D shifts the focus to future fears rather than addressing the client's current emotional state.
4. 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.
5. What is the most appropriate nursing intervention for a client with obsessive-compulsive disorder (OCD) who is constantly washing her hands?
- A. Allow the client to continue washing her hands.
- B. Set limits on the time spent washing her hands.
- C. Encourage the client to wash her hands less frequently.
- D. Assist the client in finding alternative ways to reduce anxiety.
Correct answer: D
Rationale: Assisting the client in finding alternative ways to reduce anxiety is the most appropriate intervention for a client with OCD who is constantly washing her hands. This approach helps address the underlying cause of the compulsive behavior by focusing on reducing anxiety rather than reinforcing the behavior. Allowing the client to continue washing her hands (choice A) would not address the root of the issue and may perpetuate the behavior. Setting limits on the time spent washing hands (choice B) may cause distress to the client and does not address the core problem. Encouraging the client to wash her hands less frequently (choice C) does not provide effective coping strategies for managing anxiety associated with OCD.
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