a client is admitted to the mental health unit and reports taking extra anti anxiety medication because im so stressed out i just wanted to go to slee
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HESI Mental Health

1. A client is admitted to the mental health unit and reports taking extra anti-anxiety medication because, 'I'm so stressed out. I just wanted to go to sleep.' The nurse should plan one-on-one observation of the client based on which statement?

Correct answer: D

Rationale: The correct answer is D because expressing feelings of hopelessness or nihilism can be indicators of a deeper, possibly dangerous level of depression. Choice A is incorrect as it indicates seeking help, Choice B suggests fatigue, and Choice C implies denial of needing help, none of which directly signify severe depression warranting one-on-one observation.

2. A female client with depression attends group and states that she sometimes misses her medication appointments because she feels very anxious about riding the bus. Which statement is the nurse's best response?

Correct answer: D

Rationale: The best response is to explore ways for the client to cope with anxiety (D). The nurse should encourage problem-solving rather than dependence on the case manager (A) for transportation. While taking medication for anxiety before riding the bus may be helpful, addressing coping strategies should come first (B). Although discussing the feelings of anxiety can be therapeutic (C), the most appropriate approach is to engage the client in finding ways to manage her anxiety effectively.

3. An adult male client who was admitted to the mental health unit yesterday tells the nurse that microchips were planted in his head for military surveillance of his every move. Which response is best for the LPN/LVN to provide?

Correct answer: A

Rationale: The best response for the LPN/LVN to provide is option A: 'You are in the hospital, and I am the nurse caring for you.' This response is effective as it grounds the client in the present reality while also acknowledging the client's feelings. It shows acceptance of the client's experience without directly challenging the delusional belief, which can help build rapport and trust. Option B focuses on anxiety rather than validating the client's experience or addressing the delusion. Option C suggests an unrelated activity that may not be helpful in this situation. Option D attempts to correct the client's belief, which is not likely to be effective in managing delusional thoughts.

4. When a client with schizophrenia is being discharged on antipsychotic medication, what is the most important instruction the nurse should provide?

Correct answer: C

Rationale: The correct answer is to instruct the client to report any unusual muscle movements immediately. These movements may indicate extrapyramidal symptoms (EPS) or tardive dyskinesia, which are serious side effects of antipsychotic medications that require immediate attention. Choice A is incorrect because stopping the medication without medical advice can lead to a relapse of symptoms. Choice B is important but not as critical as monitoring for EPS. Choice D is incorrect because driving readiness is not directly related to antipsychotic medication instructions.

5. 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?

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.

Similar Questions

A female client on a psychiatric unit is sweating profusely while she vigorously does push-ups and then runs the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbance, the client shouts, 'I am the boss here. I do what I want.' Which nursing problem best supports these observations?
When caring for a client with borderline personality disorder in a psychiatric unit, what is the most therapeutic nursing intervention?
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?
A RN is preparing the physical environment to interview a new client for admission to the mental health unit. Which environmental setting facilitates the best outcome of the interview?
A client is preparing to attend a Gamblers Anonymous meeting for the first time. The prototype used by this group is the 12-step program developed by Alcoholics Anonymous. Number in order of priority how the steps would be addressed.

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