HESI LPN
Mental Health HESI Practice Questions
1. What is the most important nursing intervention during the first 48 hours for a client with anorexia nervosa admitted to the hospital?
- A. Providing high-calorie, high-protein meals.
- B. Monitoring vital signs and electrolytes.
- C. Encouraging the client to talk about feelings.
- D. Observing for signs of purging.
Correct answer: B
Rationale: The most important nursing intervention during the first 48 hours for a client with anorexia nervosa is monitoring vital signs and electrolytes (B) to assess for life-threatening complications. This helps in early detection of any physiological imbalances that could lead to serious consequences. Providing high-calorie, high-protein meals (A) is important for nutritional rehabilitation but comes after ensuring the client's physical stability. Encouraging the client to talk about feelings (C) and observing for signs of purging (D) are relevant aspects of care but are not as critical as monitoring vital signs and electrolytes in the initial phase of treatment.
2. 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.
3. The community health nurse talks to a male client who has bipolar disorder. The client explains that he sleeps 4 to 5 hours a night and is working with his partner to start two new businesses and build an empire. The client stopped taking his medications several days ago. What nursing problem has the highest priority?
- A. Excessive work activity.
- B. Decreased need for sleep.
- C. Medication management.
- D. Inflated self-esteem.
Correct answer: D
Rationale: The priority is to manage the client's medication adherence to prevent escalation of manic behavior. Inflated self-esteem is the highest priority as it indicates the client's potential for harmful behaviors due to lack of medication compliance. While excessive work activity and decreased need for sleep are characteristics of mania, they are not as immediately concerning as the risk of harm related to inflated self-esteem.
4. A client is admitted to the psychiatric unit with a diagnosis of bipolar disorder, manic phase. Which activity is most appropriate for the LPN/LVN to suggest to the client?
- A. Playing a game of basketball with other clients.
- B. Taking a walk with the nurse in the garden.
- C. Working on a puzzle in a quiet room.
- D. Writing in a journal.
Correct answer: C
Rationale: During the manic phase of bipolar disorder, individuals may experience heightened levels of energy and agitation. Engaging in activities that are overly stimulating, such as playing basketball with others (choice A) or taking a walk in a garden (choice B), can exacerbate these symptoms. Writing in a journal (choice D) may also be too stimulating and may not provide the necessary distraction. Working on a puzzle in a quiet room (choice C) can offer a calming and focused activity that helps reduce anxiety and channel excess energy into a structured task, making it the most appropriate choice for a client in the manic phase of bipolar disorder.
5. A female client on the psychiatric unit tells the nurse that she feels like ending her life because she can no longer deal with her depression. What is the nurse's priority intervention?
- A. Stay with the client and ensure her safety.
- B. Inform the client that she is safe in the hospital.
- C. Document the client's statements in her medical record.
- D. Encourage the client to join a group therapy session.
Correct answer: A
Rationale: The correct answer is to stay with the client and ensure her safety. Ensuring the client's safety is the top priority when a client expresses suicidal ideation. Staying with the client can help prevent self-harm while further assessment and interventions are arranged. Choice B is incorrect because simply informing the client that she is safe in the hospital does not address the immediate need for safety. Choice C is incorrect as while documentation is important, it is not the priority when a client's safety is at risk. Choice D is also incorrect as encouraging the client to join a group therapy session is not appropriate when the client is in crisis and expressing suicidal thoughts.
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