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 female client with obsessive compulsive personality disorder is admitted to the hospital for a cardiac catheterization. The afternoon before the procedure, the client begins to keep detailed notes of the nursing care she is receiving and reports her findings to the RN at bedtime. What action should the nurse implement?
- A. Explain to the client that her behavior invades the rights of the nursing staff.
- B. Ask the client to explain why she is keeping a detailed record of her nursing care.
- C. Teach the client strategies to control her obsessive compulsive behavior.
- D. Encourage the client to express her feelings regarding the upcoming procedure.
Correct answer: D
Rationale: Encouraging the client to express her feelings can help address underlying anxieties and may reduce the need for obsessive behaviors. Choice A is incorrect because it may come across as confrontational and could escalate the situation. Choice B is not the best initial action as it focuses on the behavior rather than the client's emotions. Choice C is premature without first addressing the client's emotional needs.
3. A client is diagnosed with schizophrenia and exhibits apathy, lack of energy, and lack of interest in daily activities. The nurse should recognize that these symptoms are most likely due to which of the following?
- A. Negative symptoms of schizophrenia.
- B. Positive symptoms of schizophrenia.
- C. Side effects of antipsychotic medication.
- D. Symptoms of depression.
Correct answer: A
Rationale: Apathy, lack of energy, and lack of interest in daily activities are negative symptoms of schizophrenia (A). Positive symptoms of schizophrenia include hallucinations and delusions (B). While antipsychotic medication side effects can sometimes cause lethargy or sedation (C), the scenario specifically describes negative symptoms. Depression can also cause similar symptoms (D), but in the context of schizophrenia, these are recognized as negative symptoms.
4. The RN is providing care for a client diagnosed with borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the RN use when changing this client's dressing?
- A. Provide detailed explanations during wound cleansing.
- B. Perform the dressing change in a non-judgmental manner.
- C. Ask the client non-threateningly why they cut their abdomen.
- D. Request assistance from another staff member for the dressing change.
Correct answer: B
Rationale: Performing the dressing change in a non-judgmental manner is crucial when caring for a client with borderline personality disorder who has self-inflicted injuries. This approach helps build trust, reduces feelings of shame or guilt, and fosters a therapeutic relationship. Choice A is incorrect because while detailed explanations may be necessary, the focus should be on the non-judgmental approach. Choice C is inappropriate as it may come across as accusatory or threatening, potentially worsening the client's emotional state. Choice D is not the best option as the RN should strive to handle the situation themselves in a supportive and empathetic manner.
5. The nurse is leading a 'current events group' with chronic psychiatric clients. One group member states, 'Clara Barton was my nurse during my last hospitalization. She was a very mean nurse and wasn't nice to me.' Which response would be best for the nurse to make?
- A. 'Clara Barton was not your nurse.'
- B. 'What did she do to you that was so mean?'
- C. 'I didn't know that Clara Barton was a nurse.'
- D. 'Clara Barton started the American Red Cross.'
Correct answer: D
Rationale: (D) presents the reality of the situation in relation to American culture. The fact that Clara Barton was a nurse during the Civil War should be addressed on an individual basis. Since this is group therapy, the nurse would be illustrating the concept of universality. (A) is likely to promote defensiveness. (B and C) would support the delusion. Therefore, the most appropriate response is (D) as it provides factual information that can redirect the conversation in a constructive manner.
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