HESI LPN
Mental Health HESI 2023
1. A client with depression reports difficulty sleeping. What is the most appropriate nursing intervention?
- A. Encourage the client to take short naps during the day.
- B. Suggest the client drink a warm beverage before bedtime.
- C. Recommend the client exercise immediately before bedtime.
- D. Advise the client to take a sleep aid nightly.
Correct answer: B
Rationale: The most appropriate nursing intervention for a client with depression reporting difficulty sleeping is to suggest the client drink a warm beverage before bedtime. A warm beverage can promote relaxation and help establish a bedtime routine, which may aid in improving sleep quality. Encouraging short naps during the day (Choice A) may disrupt the client's nighttime sleep pattern. Recommending exercise immediately before bedtime (Choice C) can have a stimulating effect, making it harder for the client to fall asleep. Advising the client to take a sleep aid nightly (Choice D) should only be considered after other non-pharmacological interventions have been attempted and in consultation with a healthcare provider due to potential side effects and risks associated with sleep aids.
2. A client with major depressive disorder is prescribed an SSRI. After one week, the client reports feeling no improvement in mood. What is the best response by the RN?
- A. It is common for antidepressants to take several weeks to have an effect.
- B. We may need to switch to a different medication.
- C. You should feel better by now, let's discuss this with your doctor.
- D. Maybe you are not taking the medication as prescribed.
Correct answer: A
Rationale: The correct response is A: 'It is common for antidepressants to take several weeks to have an effect.' This response is appropriate because SSRI and other antidepressants often require several weeks to exhibit improvement in mood. It is crucial to educate the client about this delay to manage expectations and promote adherence to the medication regimen. Choice B is incorrect as switching medications prematurely is not typically recommended after just one week. Choice C is incorrect because it sets unrealistic expectations for immediate improvement. Choice D is incorrect as it may come across as accusatory and should not be the initial response.
3. A client with post-traumatic stress disorder (PTSD) is experiencing a flashback. What is the nurse's priority action?
- A. Encourage the client to talk about the trauma.
- B. Help the client to focus on the present.
- C. Administer prescribed anti-anxiety medication.
- D. Leave the client alone to work through the flashback.
Correct answer: B
Rationale: The priority action is to help the client focus on the present (B), which can reduce the intensity of the flashback. Encouraging discussion of the trauma (A) should be done when the client is not actively experiencing a flashback. While medication (C) may be necessary, it is not the first priority in this situation. Leaving the client alone (D) is not appropriate as they need support to manage the flashback.
4. A nurse working in the emergency room of a children's hospital admits a child whose injuries could have resulted from abuse. Which statement most accurately describes the nurse's responsibility in cases of suspected child abuse?
- A. Obtain objective data such as x-rays before reporting suspicions.
- B. Confirm suspicions of abuse with the physician.
- C. Report any case of suspected child abuse.
- D. Document injuries to confirm suspected abuse.
Correct answer: C
Rationale: The correct answer is C: 'Report any case of suspected child abuse.' Nurses are mandated reporters, which means they are legally obligated to report any suspicions of child abuse to appropriate authorities to ensure the child's safety. This responsibility overrides the need to gather additional data or confirm suspicions with others before reporting. Choice A is incorrect because delaying reporting to gather more data may risk the child's safety. Choice B is incorrect because reporting suspicions promptly is crucial, and waiting to confirm with another healthcare provider could delay necessary intervention. Choice D is incorrect as the priority is to report suspicions promptly rather than focusing on documenting injuries to confirm abuse.
5. A client with bipolar disorder is being treated with lithium. The nurse should monitor the client for which early sign of lithium toxicity?
- A. Diarrhea
- B. Tremors
- C. Polyuria
- D. Blurred vision
Correct answer: A
Rationale: Corrected Rationale: Diarrhea is an early sign of lithium toxicity. When a client being treated with lithium presents with diarrhea, it can indicate the beginning of lithium toxicity. Monitoring for this symptom is crucial as it can progress to more severe toxicity if not addressed promptly. Tremors (choice B) are more commonly associated with the therapeutic effects of lithium rather than toxicity. Polyuria (choice C) is a common side effect of lithium, but it is not typically an early sign of toxicity. Blurred vision (choice D) is not a common early sign of lithium toxicity. Therefore, option A is the correct answer.
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