a nurse is assessing a client with post traumatic stress disorder ptsd who reports having frequent nightmares what is the nurses best response
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Nursing Elites

HESI LPN

Mental Health HESI 2023

1. A client with post-traumatic stress disorder (PTSD) reports having frequent nightmares. What is the nurse's best response?

Correct answer: C

Rationale: The best response for the nurse is to discuss relaxation techniques with the client that can help reduce anxiety and stress before bedtime. This approach may potentially decrease the frequency of nightmares by promoting a more calming and peaceful pre-sleep routine. Choice A is incorrect because while nightmares can be common with PTSD, it is not guaranteed that they will decrease over time. Choice B is incorrect as avoiding thinking about the trauma may not address the underlying issue causing the nightmares. Choice D is incorrect as prescribing a sleep aid should be considered as a last resort after trying non-pharmacological interventions.

2. 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.

Correct answer: D

Rationale: The correct order of addressing the 12-step program typically begins with admitting powerlessness over the addiction and recognizing the unmanageability of one's life (Choice C). Following this, individuals move towards acknowledging their wrongs and sharing them with others (Choice A), then being ready to work on changing their character defects (Choice B), and finally, integrating the 12-step principles into their daily lives and helping others (Choice D). Choices A, B, and C are important steps in the program but come after admitting powerlessness and unmanageability, which is why Choice D is the correct answer.

3. The LPN/LVN is caring for a client who has been prescribed a monoamine oxidase inhibitor (MAOI) for depression. Which statement by the client indicates a need for further teaching?

Correct answer: C

Rationale: The statement 'I can drink alcohol in moderation while taking this medication' indicates a need for further teaching because alcohol consumption can have dangerous interactions with MAOIs. MAOIs can interact with alcohol to cause a hypertensive crisis, which can be life-threatening. Choices A and B are correct statements as avoiding tyramine-rich foods and taking the medication with food can help prevent adverse effects. Choice D is incorrect because abruptly stopping an antidepressant medication like an MAOI can lead to withdrawal symptoms and a relapse of depression.

4. The LPN/LVN is caring for a client who is experiencing alcohol withdrawal. Which intervention should the nurse implement first?

Correct answer: B

Rationale: When caring for a client experiencing alcohol withdrawal, the first intervention the nurse should implement is to monitor the client's vital signs. Vital sign monitoring is crucial to assess for any potential complications such as hypertension, tachycardia, fever, or other signs of autonomic hyperactivity. Administering medication like lorazepam (Ativan) would come after assessing the vital signs to determine the need for pharmacological intervention. Placing the client on seizure precautions is important, but assessing vital signs takes precedence to ensure immediate safety. Encouraging the client to express feelings about withdrawal is a supportive intervention but does not address the immediate physiological risk associated with alcohol withdrawal.

5. Which statement about contemporary mental health nursing practice is accurate?

Correct answer: D

Rationale: The accurate statement about contemporary mental health nursing practice is that the psychiatric nursing client may be an individual, family, group, organization, or community. Mental health nursing extends beyond individual care to address the impact of psychiatric stressors on families, groups, and entire communities. Choices A, B, and C are incorrect: A is false as there are various theoretical frameworks used in psychiatric nursing, B is inaccurate as psychiatric nursing is a core discipline in mental health, and C is wrong as contemporary psychiatric nursing involves various settings beyond just inpatient care.

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