a 38 year old female client is admitted with a diagnosis of paranoid schizophrenia when her tray is brought to her she refuses to eat and tells the nu
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Nursing Elites

HESI LPN

HESI Mental Health 2023

1. A 38-year-old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her, she refuses to eat and tells the nurse, 'I know you are trying to poison me with that food.' Which response would be most appropriate for the nurse to make?

Correct answer: A

Rationale: Choice (A) offers support without confrontation, allowing the client to feel safe and respected. Choices (B) and (C) directly challenge the client's delusion, which can increase anxiety and distrust. Choice (D) focuses on a non-essential issue and does not address the client's immediate emotional needs.

2. A client with obsessive-compulsive disorder (OCD) repeatedly checks the locks on the doors. What is the most therapeutic nursing intervention?

Correct answer: B

Rationale: The most therapeutic nursing intervention for a client with obsessive-compulsive disorder (OCD) who repeatedly checks locks is to encourage the client to discuss the thoughts and feelings behind the behavior. By exploring the underlying anxiety and triggers, the client can work towards understanding and managing their compulsions. Choice A is incorrect because allowing the client to continue the behavior does not address the root cause or help modify the behavior. Choice C is inappropriate as restricting access to locks can increase anxiety and worsen symptoms. Choice D of scheduling specific times for checking locks does not address the underlying psychological issues driving the behavior.

3. A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and low motivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?

Correct answer: B

Rationale: Teaching the client to develop a plan for daily structured activities is the most effective intervention in this case. Creating a routine can help improve motivation and provide a sense of accomplishment, aiding in the recovery process. Option A, providing education on methods to enhance sleep, may address hypersomnia but does not directly target psychomotor retardation and low motivation. Option C, suggesting the client develop a list of pleasurable activities, may not address the need for structure and routine. Option D, encouraging the client to exercise, is beneficial but may not be as effective as creating a structured daily plan to address the client's specific symptoms.

4. A client who has just been sexually assaulted is calm and quiet. The nurse analyzes this behavior as indicating which defense mechanism?

Correct answer: A

Rationale: The correct answer is A: Denial. In this situation, the client's calm and quiet demeanor after a traumatic event like sexual assault may indicate denial, a defense mechanism where the individual refuses to acknowledge the reality of the distressing event. Choice B, Projection, involves attributing one's thoughts or feelings to others. Choice C, Rationalization, is a defense mechanism where logical reasoning is used to justify behaviors or feelings. Choice D, Intellectualization, is a defense mechanism where excessive reasoning or logic is used to avoid uncomfortable emotions.

5. A client with major depressive disorder is prescribed an SSRI. After one week, the client reports feeling no improvement in mood. What is the best response by the RN?

Correct answer: A

Rationale: The correct response is A: 'It is common for antidepressants to take several weeks to have an effect.' This response is appropriate because SSRI and other antidepressants often require several weeks to exhibit improvement in mood. It is crucial to educate the client about this delay to manage expectations and promote adherence to the medication regimen. Choice B is incorrect as switching medications prematurely is not typically recommended after just one week. Choice C is incorrect because it sets unrealistic expectations for immediate improvement. Choice D is incorrect as it may come across as accusatory and should not be the initial response.

Similar Questions

A female client with severe depression who has been on antidepressants for two weeks suddenly becomes more energetic and talkative. What action should the RN take first?
The nurse is taking a history for a female client who is requesting a routine female exam. Which assessment finding requires follow-up?
A client with schizophrenia is experiencing delusions. What is the most appropriate nursing intervention?
A client with anorexia nervosa is being treated in an inpatient unit. Which intervention is a priority for the nurse?
A nurse is caring for a client with major depressive disorder who is withdrawn and refuses to participate in group activities. What is the best nursing intervention?

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