a teenaged male client is admitted to the postoperative unit following open reduction of a fractured femur which occurred when he fell down the stairs
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Nursing Elites

HESI LPN

HESI Mental Health 2023

1. A teenaged male client is admitted to the postoperative unit following open reduction of a fractured femur which occurred when he fell down the stairs at a party. The nurse notices needle marks on the client's arms and plans to observe for narcotic withdrawal. Early signs of narcotic withdrawal include which assessment findings?

Correct answer: D

Rationale: Agitation, sweating, and abdominal cramps are early signs of narcotic withdrawal. Vomiting, seizures, and loss of consciousness (Option A) are more indicative of severe withdrawal or overdose symptoms. Depression, fatigue, and dizziness (Option B) are not typically early signs of narcotic withdrawal. Hypotension, shallow respirations, and dilated pupils (Option C) are more associated with opioid overdose rather than withdrawal. Monitoring for agitation, sweating, and abdominal cramps is crucial for managing narcotic withdrawal symptoms effectively.

2. A LVN/LPN is caring for a client with anorexia nervosa. The nurse is monitoring the behavior of the client and understands that a client with anorexia nervosa manages anxiety by:

Correct answer: C

Rationale: Clients with anorexia nervosa often manage anxiety by adhering strictly to rules and regulations as a way to maintain control. Choice A is incorrect because engaging in immoral acts is not a common coping mechanism for clients with anorexia nervosa. Choice B is incorrect as self-approval is not typically the primary way clients with anorexia nervosa manage anxiety. Choice D is incorrect because while clients with anorexia nervosa may have a need to make the right decision, it is not the primary way they manage their anxiety.

3. A client is on a methadone maintenance program for opioid addiction. What is the most important assessment to perform?

Correct answer: C

Rationale: The most important assessment to perform for a client on a methadone maintenance program is to evaluate the client's respiratory status. Methadone can cause respiratory depression as a side effect, making it crucial to monitor the client's breathing to prevent potential complications. Monitoring for signs of withdrawal (choice A) is important but not the most critical in this scenario. Assessing for signs of methadone toxicity (choice B) is relevant, but respiratory status takes precedence due to the risk of respiratory depression. Checking the client's blood pressure regularly (choice D) is important for overall assessment but is not as crucial as monitoring respiratory status in this case.

4. The charge nurse is collaborating with the nursing staff about the plan of care for a client who is very depressed. What is the most important intervention to implement during the first 48 hours after the client's admission to the unit?

Correct answer: B

Rationale: The most critical intervention to implement during the first 48 hours after admitting a depressed client is to maintain safety (B). Depression increases the risk of suicide; hence ensuring a safe environment is the priority. While monitoring appetite (A), providing supportive contact (C), and encouraging participation in activities (D) are important aspects of care for a depressed client, ensuring safety takes precedence in the initial phase of admission.

5. A client with schizophrenia is experiencing auditory hallucinations. What is the most appropriate nursing intervention?

Correct answer: A

Rationale: The most appropriate nursing intervention for a client with schizophrenia experiencing auditory hallucinations is to encourage the client to focus on reality-based activities. This intervention helps redirect their attention away from hallucinations, promoting engagement with the environment. Choice B is incorrect as telling the client that the voices are not real may invalidate their experiences and worsen the therapeutic relationship. Choice C may increase the client's distress by focusing on the hallucinations. Choice D might not be helpful as interacting with others who are not experiencing hallucinations may not address the client's current needs.

Similar Questions

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A client with a diagnosis of schizophrenia is prescribed risperidone (Risperdal). Which statement by the client indicates a need for further teaching?
A client is admitted to the hospital with a diagnosis of anorexia nervosa. What is the most important intervention for the LPN/LVN to implement during the first 24 hours of hospitalization?
A male client with mental illness and substance dependency tells the mental health nurse that he has started using illegal drugs again and wants to seek treatment. Since he has a dual diagnosis, which person is best for the nurse to refer this client to first?
What information should the nurse include in the client's teaching about starting a selective serotonin reuptake inhibitor (SSRI) for major depressive disorder?

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