HESI LPN
Mental Health HESI 2023
1. A female client with schizophrenia is experiencing auditory hallucinations. What is the most therapeutic response by the nurse?
- A. I don't hear any voices. They must be in your head.
- B. What are the voices telling you to do?
- C. You need to ignore the voices and focus on reality.
- D. I know the voices are real to you, but I don't hear them.
Correct answer: D
Rationale: Acknowledging the client's experience while gently presenting reality can help build trust and provide reassurance without reinforcing the hallucination.
2. A client with a history of heart failure is admitted with weight gain and peripheral edema. Which medication should the LPN/LVN anticipate being prescribed?
- A. Lisinopril (Zestril)
- B. Furosemide (Lasix)
- C. Metoprolol (Lopressor)
- D. Simvastatin (Zocor)
Correct answer: B
Rationale: Furosemide (Lasix) is the correct answer. In a client with heart failure experiencing weight gain and peripheral edema, the priority is to manage fluid overload. Furosemide is a loop diuretic commonly prescribed to reduce excess fluid in heart failure patients. Lisinopril (Zestril) is an ACE inhibitor used to treat hypertension and heart failure but does not directly address fluid overload. Metoprolol (Lopressor) is a beta-blocker that helps manage heart failure symptoms but does not primarily target fluid retention. Simvastatin (Zocor) is a statin used to lower cholesterol levels and is not indicated for managing fluid overload in heart failure.
3. An older client is admitted to the psychiatric unit for assessment of a recent onset of dementia. The PN notes that in the evening this client often becomes restless, confused, and agitated. Which intervention is most important for the PN to implement?
- A. Ask family members to remain with the client in the evenings from 5 to 8 pm
- B. Administer a prescribed PRN benzodiazepine at the onset of a confused state
- C. Ensure that the client is assigned to a room close to the nurses' station
- D. Postpone administration of nighttime medications until after 11 pm
Correct answer: C
Rationale: Sundowning, a phenomenon where dementia symptoms worsen in the evening, can be managed by ensuring the client is close to the nurses' station for frequent monitoring and quick intervention, if necessary. This reduces the risk of harm and helps manage agitation. Asking family members to remain with the client may not always be feasible and does not address the need for close monitoring. Administering benzodiazepines should not be the first-line intervention for sundowning as it can increase the risk of falls and other adverse effects. Postponing medication administration may disrupt the client's routine and potentially worsen symptoms.
4. A client with a diagnosis of generalized anxiety disorder is prescribed hydroxyzine. The nurse should instruct the client that this medication may have which potential side effect?
- A. Drowsiness
- B. Dry mouth
- C. Nausea
- D. Headache
Correct answer: A
Rationale: The correct answer is A: Drowsiness. Hydroxyzine is known to cause drowsiness, so clients should be advised to avoid activities like driving until they understand how the medication affects them. Choices B, C, and D are incorrect because dry mouth, nausea, and headache are not commonly associated with hydroxyzine use. It is crucial for the client to be aware of the potential drowsiness to ensure their safety and well-being while taking this medication.
5. When washing soiled hands, what should the nurse do after wetting the hands and applying soap?
- A. Rub hands palm to palm
- B. Interlace the fingers
- C. Dry hands with a paper towel
- D. Turn off the water faucet
Correct answer: A
Rationale: After wetting the hands and applying soap, the nurse should rub hands palm to palm. Rubbing hands palm to palm helps create friction and effectively clean the hands by spreading the soap and reaching all areas. Interlacing the fingers, drying hands with a paper towel, and turning off the water faucet should come after rubbing hands palm to palm in the handwashing process. Interlacing the fingers can be done to ensure the backs of the hands are cleaned, drying hands with a paper towel is the final step to ensure hands are dry, and turning off the water faucet helps save water.