HESI LPN
Mental Health HESI 2023
1. A client with a history of substance abuse is admitted to the hospital for detoxification. What is the most important intervention for the LPN/LVN to implement?
- A. Monitor the client for signs of withdrawal.
- B. Encourage the client to express feelings about substance use.
- C. Provide the client with information about support groups.
- D. Administer prescribed medications to manage withdrawal symptoms.
Correct answer: D
Rationale: Administering prescribed medications to manage withdrawal symptoms is the priority intervention for a client undergoing detoxification. This intervention aims to prevent severe complications that may arise during the detox process. Monitoring for signs of withdrawal (choice A) is important but providing immediate medical management through medications takes precedence to ensure the client's safety. Encouraging the client to express feelings (choice B) and providing information about support groups (choice C) are essential aspects of care but are not as urgent as administering medications to manage withdrawal symptoms.
2. A client in the manic phase of bipolar disorder is pacing the hallway and talking rapidly. What is the best intervention for the nurse?
- A. Encourage the client to join a group activity.
- B. Offer the client a high-calorie snack and a drink.
- C. Direct the client to a quieter area of the unit.
- D. Instruct the client to sit down and relax.
Correct answer: B
Rationale: In the manic phase of bipolar disorder, clients often exhibit increased activity and may burn a lot of energy. Offering a high-calorie snack and a drink is the best intervention as it helps maintain their nutritional needs while allowing them to continue their activity. Encouraging the client to join a group activity (Choice A) may further stimulate their behavior. Directing the client to a quieter area (Choice C) might not address their energy expenditure. Instructing the client to sit down and relax (Choice D) may not be effective during the manic phase.
3. A woman arrives in the Emergency Center and tells the nurse she thinks she has been raped. The client is sobbing and expresses disbelief that a rape could happen because the man is her best friend. After acknowledging the client's fear and anxiety, how should the nurse respond?
- A. I would be very upset and mad if my best friend did that to me.
- B. You must feel betrayed, but maybe you might have led him on?
- C. Rape is not limited to strangers and frequently occurs by someone who is known to the victim.
- D. This does not sound like rape. Did you change your mind about having sex after the fact?
Correct answer: C
Rationale: A victim of date rape or acquaintance rape is less prone to recognize what is happening because the incident usually involves persons who know each other and the dynamics are different than rape by a stranger. Choice (C) provides confrontation for the client's denial because the victim frequently knows and trusts the perpetrator. Nurses should not express personal feelings (Choice A) when dealing with victims. Choice B, suggesting that the client led on the rapist, indicates that the sexual assault was somehow the victim's fault. Choice D is judgmental and does not display compassion or establish trust between the nurse and the client.
4. How should the RN respond to the mother?
- A. Ask the mother if she has ever thought about harming herself or her child.
- B. Reassure the mother that her child will achieve some growth and development milestones.
- C. Determine if the mother has other children who do not have developmental disabilities.
- D. Encourage the mother to write her thoughts and feelings in a journal.
Correct answer: A
Rationale: The correct response is to ask the mother if she has ever thought about harming herself or her child. This is crucial to assess for suicidal or homicidal thoughts, ensuring the safety of both the mother and the child. Reassuring the mother about achieving some milestones may not address her immediate emotional distress. Inquiring about other children's developmental status is not the priority when safety concerns are present. While journaling can be therapeutic, in this situation, addressing safety takes precedence.
5. A female client with schizophrenia is experiencing auditory hallucinations. What is the most therapeutic response by the nurse?
- A. I don't hear any voices. They must be in your head.
- B. What are the voices telling you to do?
- C. You need to ignore the voices and focus on reality.
- D. I know the voices are real to you, but I don't hear them.
Correct answer: D
Rationale: Acknowledging the client's experience while gently presenting reality can help build trust and provide reassurance without reinforcing the hallucination.
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