HESI LPN
Mental Health HESI Practice Questions
1. A nurse is providing discharge teaching to a client with major depressive disorder who is prescribed fluoxetine (Prozac). What is the most important teaching point for the nurse to include?
- A. You may experience dizziness, so avoid driving.
- B. It may take several weeks to feel the full effect of the medication.
- C. Avoid foods high in tyramine while taking this medication.
- D. Take this medication only when you feel depressed.
Correct answer: B
Rationale: The correct answer is B because SSRIs like fluoxetine typically take several weeks to reach their full therapeutic effect, so it's important to set realistic expectations for the client. Choice A is incorrect as dizziness is a common side effect but not the most important teaching point. Choice C is incorrect as avoiding tyramine-rich foods is more relevant for MAOIs. Choice D is incorrect as fluoxetine should be taken consistently, not only when the client feels depressed, to maintain therapeutic blood levels.
2. A female client refuses to take an oral hypoglycemic agent because she believes that the drug is being administered as part of an elaborate plan by the Mafia to harm her. Which nursing intervention is most important to include in this client's plan of care?
- A. Reassure the client that no one will harm her while she is in the hospital.
- B. Ask the healthcare provider to give the client the medication.
- C. Explain the importance of taking the diabetic medication.
- D. Reassess the client's mental status for thought processes and content.
Correct answer: D
Rationale: Reassessing the client's mental status is the most important intervention as it is crucial to address the client's delusional thinking. By assessing the client's thought processes and content, the nurse can gain insight into the client's beliefs and tailor interventions accordingly. Reassuring the client that no harm will come to her, asking the healthcare provider to give the medication, or simply explaining the importance of taking the medication may not effectively address the underlying issue of delusional beliefs.
3. When assessing a client's IV for infiltration, which finding would be unexpected for the nurse?
- A. The area around the infusion site feels warm to the touch.
- B. The infusion site is swollen and cool to the touch.
- C. The infusion line does not flush properly.
- D. There is no blood return in the infusion line.
Correct answer: A
Rationale: The correct answer is A. Warmth around the infusion site is not an expected finding with infiltration. Infiltration typically presents with swelling and coolness due to the fluid leaking into the surrounding tissue. Choices B, C, and D are incorrect because swelling, coolness, and difficulty flushing the line, as well as lack of blood return, are commonly associated with infiltration.
4. A client had a mastectomy 6 months ago and expresses a decreased desire for sexual relations, stating “My body is so different now.” Which of the following responses should the nurse make?
- A. “Really, you look just fine to me. There’s no need to feel undesirable.”
- B. “I’m interested in finding out more about how your body feels to you.”
- C. “Consider an afternoon at a spa; a facial will make you feel more attractive.”
- D. “It’s still too soon to expect to feel normal. Give it a little more time.”
Correct answer: B
Rationale: In this situation, the appropriate response is to reflect on the client’s feelings and explore their experience. Choice A may unintentionally dismiss the client's concerns by not addressing their emotional needs. Choice C suggests a spa treatment as a solution without addressing the underlying emotional issues. Choice D implies that the client's feelings will resolve with time, which may not be helpful in addressing the client's current emotional state.
5. The patient refuses a morning bath, stating a preference for evening baths. What is the best action for the nurse to take?
- A. Defer the bath until evening and pass on the information to the next shift.
- B. Tell the patient that daily morning baths are the 'normal' routine.
- C. Explain the importance of maintaining morning hygiene practices.
- D. Cancel hygiene for the day and attempt again in the morning.
Correct answer: A
Rationale: The best action for the nurse is to respect the patient's preference and autonomy. By deferring the bath until evening, the nurse acknowledges and accommodates the patient's routine, promoting patient-centered care. Choice B could be seen as dismissive of the patient's preference and may not foster a therapeutic relationship. Choice C, while important, doesn't address the patient's current refusal. Choice D is not respectful of the patient's autonomy and could lead to increased resistance. Therefore, option A is the most appropriate and patient-centered approach.