a client is admitted to the hospital with a diagnosis of anorexia nervosa what is the most important intervention for the lpnlvn to implement during t
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Nursing Elites

HESI LPN

HESI Mental Health 2023

1. A client is admitted to the hospital with a diagnosis of anorexia nervosa. What is the most important intervention for the LPN/LVN to implement during the first 24 hours of hospitalization?

Correct answer: B

Rationale: The correct answer is to monitor the client's vital signs and weight. This intervention is crucial in assessing the severity of the client's condition and planning appropriate care. Vital signs and weight monitoring help in evaluating the client's physiological status and identifying any immediate concerns related to anorexia nervosa. Choices A, C, and D are important aspects of care for a client with anorexia nervosa; however, during the initial 24 hours of hospitalization, monitoring vital signs and weight takes precedence as it provides essential data for the client's ongoing management and treatment.

2. An older female adult who lives in a nursing home is loudly demanding that the nurse call her son who has been deceased for five years. Which intervention should the nurse implement?

Correct answer: D

Rationale: In this situation, the most appropriate intervention is to direct the client to a new activity. This approach can help redirect the client's attention, distract her from the distressing request, and engage her in a more positive interaction. Choice A could exacerbate the client's distress by attempting to make the impossible call, and reminding the client about her son's passing (Choice B) may increase her emotional distress. Escorting the client to a private area (Choice C) does not address the underlying issue and may not effectively manage the situation.

3. How should the RN respond to the mother?

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.

4. A client with depression is prescribed an SSRI. The client asks, 'Why do I need to take this medication every day?' What is the best response by the nurse?

Correct answer: D

Rationale: Explaining that the medication may take several weeks to take full effect helps manage the client's expectations and encourages adherence to the prescribed treatment.

5. During an annual physical by the occupational nurse working in a corporate clinic, a male employee tells the nurse that his high-stress job is causing trouble in his personal life. He further explains that he often gets so angry while driving to and from work that he has considered 'getting even' with other drivers. How should the nurse respond?

Correct answer: C

Rationale: The correct responses are C and D. The nurse should acknowledge the employee's feelings of anger and suggest that expressing anger to strangers, like other drivers, could lead to unsafe situations. This response aims to prevent potential confrontations or harm. Choice A is incorrect as it doesn't address the specific situation of expressing anger while driving. Choice B is also incorrect as it is vague and doesn't provide practical advice to manage the anger effectively.

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