a young adult male with a history of substance abuse is admitted to the psychiatric unit for detoxification he is agitated sweating and reports seeing
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Nursing Elites

HESI LPN

HESI Mental Health 2023

1. A young adult male with a history of substance abuse is admitted to the psychiatric unit for detoxification. He is agitated, sweating, and reports seeing bugs crawling on the walls. What is the priority nursing intervention?

Correct answer: B

Rationale: The correct answer is to administer the prescribed benzodiazepine. This intervention helps manage the client's agitation and hallucinations, which are common symptoms during detoxification from substances. Reassuring the client that the bugs are not real (Choice A) may not be effective in addressing the underlying causes of the hallucinations. Placing the client in a quiet, dark room (Choice C) may help reduce sensory stimulation but does not directly address the client's symptoms. Encouraging the client to express his feelings (Choice D) is important for therapeutic communication but may not be the priority when the client is experiencing severe agitation and hallucinations.

2. The LPN/LVN is caring for a client with depression who has been prescribed an SSRI. The client reports feeling more energy but is still feeling hopeless. What should the nurse be most concerned about?

Correct answer: A

Rationale: The nurse should be most concerned that the client may act on suicidal thoughts. An increase in energy combined with persistent feelings of hopelessness can indicate a higher risk of suicide. While impulsive behavior can be a concern, the primary worry should be the client's safety regarding suicidal ideation. Side effects of the medication are important to monitor but do not take precedence over the risk of self-harm. Serotonin syndrome is a potential concern with SSRIs, but in this scenario, the client's mental health and safety are the immediate priority.

3. A female client with bulimia nervosa is admitted to the hospital. Which intervention should the nurse include in the plan of care?

Correct answer: B

Rationale: The correct intervention for a client with bulimia nervosa is to observe the client for 30 minutes after meals. This helps prevent purging behaviors, such as vomiting or using laxatives, which are common in bulimia nervosa. Choice A is incorrect because eating meals alone may enable the client to engage in purging behaviors without being observed. Choice C is incorrect as a high-calorie diet may exacerbate the client's concerns about weight gain. Choice D is incorrect because encouraging daily weigh-ins can reinforce obsessive thoughts about weight and body image.

4. A client with depression is started on a selective serotonin reuptake inhibitor (SSRI). What should the LPN/LVN include in the teaching plan?

Correct answer: C

Rationale: Teaching the client that the medication may take 4 to 6 weeks to become fully effective is crucial as it helps set realistic expectations. While choice A is important to reduce nausea, it is not the most critical information to provide initially. Choice B is incorrect as improvement usually occurs after several weeks of treatment, not within 1 to 2 weeks. Choice D is also relevant, but informing about the full effectiveness of the medication is more important for long-term adherence.

5. A client with obsessive-compulsive disorder (OCD) repeatedly checks the locks on the doors. What is the best nursing intervention?

Correct answer: A

Rationale: The best nursing intervention when dealing with a client with OCD who repeatedly checks locks is to encourage the client to discuss their fears. This approach can help the client identify underlying anxiety triggers and work towards developing alternative coping mechanisms. Choice B, limiting the client's time for ritualistic behavior, may increase anxiety and worsen symptoms by creating a sense of urgency. Choice C, assisting the client to complete the ritual faster, does not address the underlying issues and may reinforce the behavior. Choice D, preventing the client from engaging in the behavior, can lead to increased anxiety and distress for the client.

Similar Questions

The RN documents the mental status of a female client who has been hospitalized for several days by court order. The client states 'I don't need to be here,' and tells the RN that she believes that the TV talks to her. The RN should document these assessment statements in which section of the mental status exam?
The nurse observes a client who is admitted to the mental health unit and identifies that the client is talking continuously, using words that rhyme but that have no context or relationship with one topic to the next in the conversation. This client's behavior and thought processes are consistent with which syndrome?
A client with schizophrenia is being treated with haloperidol (Haldol). The client reports feeling restless and unable to sit still. What should the nurse do first?
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 female client on a psychiatric unit is sweating profusely while she vigorously does push-ups and then runs the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbance, the client shouts, 'I am the boss here. I do what I want.' Which nursing problem best supports these observations?

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