HESI LPN
Mental Health HESI Practice Questions
1. In observing a client who is pacing, agitated, and presenting aggressive gestures, with rapid speech pattern and belligerent affect, what is the immediate priority of care for the nurse?
- A. Provide safety for the client and other clients on the unit
- B. Provide the clients on the unit with a sense of comfort and safety
- C. Assist the staff in caring for the client in a controlled environment
- D. Offer the client a less stimulated area to calm down and gain control
Correct answer: A
Rationale: In a situation where a client is displaying aggression and agitation, the immediate priority of care for the nurse is to ensure safety for the client and others on the unit. Providing a safe environment and implementing calming measures take precedence over other interventions. Option A is the correct choice as it addresses the crucial need for safety in a potentially volatile situation. Options B, C, and D, although important, do not address the primary concern of ensuring safety for all individuals involved.
2. The client is planning discharge for a male client with schizophrenia. The client insists that he is returning to his apartment, although the healthcare provider informed him that he will be moving to a boarding home. What is the most important nursing diagnosis for discharge planning?
- A. Ineffective denial related to situational anxiety.
- B. Ineffective coping related to inadequate support.
- C. Social isolation related to difficult interactions.
- D. Self-care deficit related to cognitive impairment.
Correct answer: A
Rationale: The best nursing diagnosis is (A) because the client is unable to acknowledge the move to a boarding home. While (B, C, and D) are potential nursing diagnoses, denial is the most critical as it is a defense mechanism preventing the client from addressing his feelings regarding the change in living arrangements.
3. A male employee who is assessed weekly in the employee clinic for blood pressure because of a history of hypertension tells the nurse that he is so upset with one of his co-workers that he would like to shoot him. What action should the nurse take first?
- A. Determine if the client has a weapon available for use.
- B. Inform the health care provider of the threat to harm a co-worker.
- C. Notify security of the client's intention to harm a co-worker.
- D. Have the employee escorted to a mental health facility.
Correct answer: A
Rationale: Determining if the client has access to a weapon is critical for immediate safety and to prevent potential harm.
4. A child is brought to the emergency room with a broken arm. Because of other injuries, the nurse suspects the child may be a victim of abuse. When the nurse tries to give the child an injection, the child's mother becomes very loud and shouts, 'I won't leave my son! Don't you touch him! You'll hurt my child!' What is the best interpretation of the mother's statements? The mother is
- A. regressing to an earlier behavior pattern.
- B. sublimating her anger.
- C. projecting her feelings onto the nurse.
- D. suppressing her fear.
Correct answer: C
Rationale: The correct answer is (C) projecting her feelings onto the nurse. The mother's behavior suggests that she is attributing her own actions or feelings to the nurse, which is a form of projection. Option (A) regressing to an earlier behavior pattern is not the best fit in this context. Option (B) sublimating her anger is not applicable based on the given scenario. Option (D) suppressing her fear cannot be inferred from the provided information.
5. The nurse is preparing to administer phenelzine sulfate (Nardil) to a client on the psychiatric unit. Which complaint related to administration of this drug should the nurse expect this client to make?
- A. My mouth feels like cotton.
- B. That medication gives me indigestion.
- C. This pill gives me diarrhea.
- D. My urine looks pink.
Correct answer: A
Rationale: Dry mouth is a common side effect of MAO inhibitors like phenelzine due to their anticholinergic effects. Choices B, C, and D are incorrect as indigestion, diarrhea, and pink urine are not commonly associated side effects of phenelzine.
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