a teenaged client a heroin addict is admitted to the unit for detoxification what intervention is most important for the nurse to initiate during the

HESI LPN

HESI Mental Health Practice Questions

1. A teenaged client, a heroin addict, is admitted to the unit for detoxification. What intervention is most important for the nurse to initiate during the first 24 hours after admission?

A. Assign the client to a teen support group.
B. Assess intake and output.
C. Monitor for wheezing and apnea.
D. Limit visitors to family members only.

Correct answer: B

Rationale: Assessing intake and output is crucial during the first 24 hours after admission for detoxification. This helps the nurse monitor the client's hydration status and kidney function as the body goes through withdrawal from heroin. Option A is incorrect because joining a support group is beneficial but may not be the priority in the initial phase of detoxification. Option C, monitoring for wheezing and apnea, is important but not the most critical intervention during the first 24 hours. Option D, limiting visitors to family members only, is not directly related to the immediate needs of assessing intake and output.

2. A client with schizophrenia who has been stabilized on medication is being discharged from the hospital. What discharge teaching is most important for the LPN/LVN to reinforce?

A. The importance of adhering to the prescribed medication regimen.
B. How to recognize early signs of relapse.
C. The need to continue follow-up appointments with the healthcare provider.
D. The importance of maintaining a healthy lifestyle, including proper diet and exercise.

Correct answer: A

Rationale: The correct answer is A. Reinforcing the importance of adhering to the prescribed medication regimen is crucial for preventing relapse in clients with schizophrenia. Compliance with medication is essential in managing the symptoms and preventing a worsening of the condition. Choice B, recognizing early signs of relapse, is important but secondary to ensuring medication adherence. Choice C, follow-up appointments, is also important but not as critical as medication compliance immediately post-discharge. Choice D, maintaining a healthy lifestyle, is beneficial for overall health but is not as directly linked to preventing relapse in schizophrenia as medication adherence.

3. Which action should the nurse implement first for a client experiencing alcohol withdrawal?

A. Apply vest or extremity restraints.
B. Give an alpha-adrenergic blocker.
C. Provide a diet high in protein and calories.
D. Prepare the environment to prevent self-injury.

Correct answer: D

Rationale: The correct action for the nurse to implement first for a client experiencing alcohol withdrawal is to prepare the environment to prevent self-injury. Clients undergoing alcohol withdrawal are at risk of seizures and other symptoms that may lead to self-harm. By ensuring a safe environment, the nurse can mitigate the risk of injury. Applying restraints (Choice A) should only be considered if less restrictive measures fail, as restraints can agitate the client further. Giving an alpha-adrenergic blocker (Choice B) may be part of the treatment plan for alcohol withdrawal but is not the first action to take. Providing a diet high in protein and calories (Choice C) is important for overall health but is not the priority when addressing immediate safety concerns.

4. A 22-year-old male client is admitted to the emergency center following a suicide attempt. His records reveal that this is his third suicide attempt in the past two years. He is conscious, but does not respond to verbal commands for treatment. Which assessment finding should prompt the nurse to prepare the client for gastric lavage?

A. He ingested the drug 3 hours prior to admission to the emergency center.
B. The family reports that he took an entire bottle of acetaminophen (Tylenol).
C. He is unresponsive to instructions and is unable to cooperate with emetic therapy.
D. Those with repeated suicide attempts desire punishment to relieve their guilt.

Correct answer: C

Rationale: The correct answer is C because the client's unresponsiveness to instructions and inability to cooperate with emetic therapy would make it challenging to implement such therapy effectively. In such cases, gastric lavage may be necessary to remove the ingested substance. Choices A and B are important considerations in treatment planning but do not directly indicate the need for gastric lavage. Choice D is incorrect as medical treatments should never be used as punitive measures but rather for therapeutic purposes.

5. At the first meeting of a group of older adults at a daycare center for the elderly, the LPN/LVN asks one of the members what kinds of things she would like to do with the group. The older woman shrugs her shoulders and says, 'You tell me, you're the leader.' What is the best response for the nurse to make?

A. Yes, I am the leader today. Would you like to be the leader tomorrow?
B. Yes, I will be leading this group. What would you like to accomplish during this time?
C. Yes, I have been assigned to be the leader of this group. I will be here for the next six weeks.
D. Yes, I am the leader. You seem angry about not being the leader yourself.

Correct answer: B

Rationale: The best response for the nurse is choice B: 'Yes, I will be leading this group. What would you like to accomplish during this time?' This response acknowledges the member's comment and encourages her to share her interests, promoting engagement and active participation in group activities. Choice A is not as inclusive and may not foster collaboration within the group. Choice C focuses more on the nurse's assignment rather than addressing the member's input. Choice D assumes emotions that were not expressed by the group member and does not encourage open communication.