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HESI Mental Health
1. A client with bipolar disorder is prescribed lithium. What is the most important instruction the nurse should provide?
- A. Avoid foods high in potassium while taking this medication.
- B. Take your medication with food to prevent nausea.
- C. Be sure to maintain a consistent sodium intake.
- D. You can stop taking the medication once your symptoms improve.
Correct answer: C
Rationale: Maintaining a consistent sodium intake is crucial for clients taking lithium because changes in sodium levels can impact lithium concentrations, potentially leading to toxicity. It is essential to avoid excessive sodium intake, as both low and high levels can affect lithium levels. Choices A, B, and D are incorrect. A high potassium diet is not a concern with lithium therapy. While taking lithium with food can help reduce gastrointestinal side effects, it is not the most important instruction. Finally, abruptly stopping lithium can lead to a recurrence of symptoms or a worsening of the condition, so it is vital to follow the prescribed regimen.
2. A client is admitted with a diagnosis of depression. The nurse knows that which characteristic is most indicative of depression?
- A. Grandiose ideation.
- B. Self-destructive thoughts.
- C. Suspiciousness of others.
- D. A negative view of self and the future.
Correct answer: D
Rationale: A negative view of self and the future (D) is a prominent characteristic of depression. It reflects the core symptoms of low self-esteem and hopelessness that are commonly associated with this condition. Grandiose ideation (A) and suspiciousness of others (C) are more indicative of other mental health disorders like paranoia. While self-destructive thoughts (B) can be present in depression, they are not as specific and common as the negative self-view and hopelessness, making option (D) the most indicative characteristic of depression.
3. A client with anorexia nervosa is being treated in an inpatient unit. Which intervention is a priority for the nurse?
- A. Encourage the client to exercise to build muscle mass.
- B. Provide liquid supplements between meals.
- C. Allow the client to choose their own meals.
- D. Monitor the client's weight daily.
Correct answer: D
Rationale: Monitoring the client's weight daily is a priority intervention for a nurse caring for a client with anorexia nervosa. Weight monitoring is crucial in assessing the client's progress and adjusting treatment as necessary to prevent complications such as refeeding syndrome, electrolyte imbalances, and cardiac issues. Encouraging exercise (Choice A) can exacerbate the client's unhealthy relationship with food and body image. Providing liquid supplements (Choice B) is important but may not be the priority over monitoring weight. Allowing the client to choose their own meals (Choice C) may not be suitable initially as they may make unhealthy choices or avoid meals altogether.
4. A male client with alcohol use disorder is admitted for detoxification. The nurse knows that which symptom is a sign of severe alcohol withdrawal?
- A. Bradycardia
- B. Seizures
- C. Hyperglycemia
- D. Constipation
Correct answer: B
Rationale: Seizures are a sign of severe alcohol withdrawal and can be life-threatening, requiring immediate medical attention. Bradycardia, hyperglycemia, and constipation are not typically associated with severe alcohol withdrawal. Bradycardia is more commonly seen in opioid withdrawal, hyperglycemia could be due to other reasons like uncontrolled diabetes, and constipation is not a typical symptom of severe alcohol withdrawal.
5. A nurse working in a psychiatric unit is assessing a client who appears to be responding to internal stimuli. The client is laughing and talking to himself. What is the nurse's best initial response?
- A. Approach the client and ask if he is hearing voices.
- B. Ignore the behavior as it is common in psychiatric settings.
- C. Encourage the client to express his thoughts verbally.
- D. Observe the client's behavior from a distance.
Correct answer: A
Rationale: Approaching the client and asking if he is hearing voices is the best initial response by the nurse. This action can help assess the situation and determine if the client is experiencing hallucinations that may require immediate intervention. Choice B is incorrect because ignoring the behavior could lead to missing important signs of distress or potential risks. Choice C may not address the immediate concern of assessing for hallucinations. Choice D is also not ideal as observing from a distance may not provide the necessary information for immediate assessment and intervention.
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