HESI LPN
Mental Health HESI 2023
1. A client with schizophrenia receiving haloperidol (Haldol) has a stiff, mask-like facial expression and difficulty speaking. What is the nurse's priority action?
- A. Administer a PRN dose of lorazepam (Ativan).
- B. Encourage the client to perform facial exercises.
- C. Notify the healthcare provider of possible extrapyramidal symptoms (EPS).
- D. Document the findings and continue to monitor the client.
Correct answer: C
Rationale: The correct answer is to notify the healthcare provider of possible extrapyramidal symptoms (EPS). The symptoms described, such as a stiff, mask-like facial expression and difficulty speaking, are indicative of EPS, which can be a serious side effect of haloperidol. It is crucial to involve the healthcare provider immediately to address these symptoms. Administering a PRN dose of lorazepam (Choice A) is not the priority in this situation, as it does not address the underlying cause of EPS. Encouraging the client to perform facial exercises (Choice B) is not appropriate and may not effectively manage EPS. Documenting the findings and continuing to monitor the client (Choice D) is important but not the priority when potential EPS is present; immediate action by notifying the healthcare provider is essential.
2. The wife of a male client recently diagnosed with schizophrenia asks the nurse, 'What exactly is schizophrenia? Is my husband all right?' Which response is best for the LPN/LVN to provide to this family member?
- A. It sounds like you're worried about your husband. Let's sit down and talk.
- B. It is a chemical imbalance in the brain that causes disorganized thinking.
- C. Your husband will be just fine if he takes his medications regularly.
- D. I think you should talk to your husband's psychologist about this question.
Correct answer: B
Rationale: The best response for the LPN/LVN to provide to the wife of a male client diagnosed with schizophrenia is choice B: 'It is a chemical imbalance in the brain that causes disorganized thinking.' This response educates the wife about the nature of schizophrenia, explaining that it is caused by a chemical imbalance in the brain leading to disorganized thinking, helping her understand the condition better. Choice A does not directly address the question and instead shifts the focus to a different aspect. Choice C gives false reassurance without providing necessary information about schizophrenia. Choice D deflects the responsibility of providing information to the psychologist instead of addressing the wife's concerns directly.
3. A client with anorexia nervosa is being treated in an inpatient unit. Which intervention is a priority for the nurse?
- A. Encourage the client to exercise to build muscle mass.
- B. Provide liquid supplements between meals.
- C. Allow the client to choose their own meals.
- D. Monitor the client's weight daily.
Correct answer: D
Rationale: Monitoring the client's weight daily is a priority intervention for a nurse caring for a client with anorexia nervosa. Weight monitoring is crucial in assessing the client's progress and adjusting treatment as necessary to prevent complications such as refeeding syndrome, electrolyte imbalances, and cardiac issues. Encouraging exercise (Choice A) can exacerbate the client's unhealthy relationship with food and body image. Providing liquid supplements (Choice B) is important but may not be the priority over monitoring weight. Allowing the client to choose their own meals (Choice C) may not be suitable initially as they may make unhealthy choices or avoid meals altogether.
4. 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.
5. The nurse is conducting discharge teaching for a client with schizophrenia who plans to live in a group home. Which statement is most indicative of the need for careful follow-up after discharge?
- A. Crickets are a good source of protein.
- B. I have not heard any voices for a week.
- C. Only my belief in God can help me.
- D. Sometimes I have a hard time sitting still.
Correct answer: C
Rationale: The correct answer is C. The statement 'Only my belief in God can help me' suggests a reliance on spiritual intervention over medical treatment, raising concerns about potential non-compliance. This indicates the need for close follow-up to ensure the client's well-being and adherence to the prescribed treatment plan. Choices A, B, and D do not directly address potential issues related to treatment compliance or the need for follow-up care after discharge.
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