an older homeless client visits the psychiatric clinic to obtain a prescription renewal for alprazolam xanax during the health assessment the client c
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Nursing Elites

HESI LPN

HESI Mental Health Practice Exam

1. An older homeless client visits the psychiatric clinic to obtain a prescription renewal for alprazolam (Xanax). During the health assessment, the client complains of chest pain. Which action should the RN take first?

Correct answer: D

Rationale: Determining if Xanax was taken recently is crucial as it helps assess whether the chest pain is related to medication use or another issue, guiding appropriate immediate care. This action can provide essential information to address the client's current complaint effectively. Referring the client to the cardiology unit (Choice A) may be premature without assessing the Xanax use first. While obtaining the client's blood pressure (Choice B) is important, it is not the priority when the client presents with chest pain and a history of taking Xanax. Assessing the client for substance abuse (Choice C) is also important but is secondary to first determining the potential link between Xanax and the chest pain.

2. Two days after his last drink, a male alcoholic client becomes agitated and yells at his wife and children, 'Stay away from me!' His vital signs are elevated. What nursing diagnosis has the highest priority?

Correct answer: D

Rationale: The correct answer is 'High risk for injury.' The client's agitation, elevated vital signs, and aggressive behavior pose a threat to himself and his family. Addressing the risk for injury is the priority to ensure the safety of all individuals involved. Choices A, B, and C are not the highest priority in this scenario. 'High risk for social isolation' does not address the immediate physical safety concern. 'Altered parenting' and 'Ineffective individual coping' are important but not as urgent as the risk for injury in this situation.

3. A male client with alcohol use disorder is admitted for detoxification. The nurse knows that which symptom is a sign of severe alcohol withdrawal?

Correct answer: B

Rationale: Seizures are a sign of severe alcohol withdrawal and can be life-threatening, requiring immediate medical attention. Bradycardia, hyperglycemia, and constipation are not typically associated with severe alcohol withdrawal. Bradycardia is more commonly seen in opioid withdrawal, hyperglycemia could be due to other reasons like uncontrolled diabetes, and constipation is not a typical symptom of severe alcohol withdrawal.

4. A client on the psychiatric unit appears to imitate a certain nurse on the unit. The client seeks out this particular nurse and imitates the nurse's mannerisms. The nurse knows that the client is using which defense mechanism?

Correct answer: B

Rationale: The correct answer is (B) Identification. In this scenario, the client is imitating the nurse's mannerisms, which is a form of identification, a defense mechanism where an individual adopts the characteristics or behaviors of someone they admire or view as powerful. (A) Sublimation involves channeling unacceptable impulses into socially acceptable actions, not imitation. (C) Introjection is the internalization of external qualities or attributes, not imitation. (D) Repression is the unconscious exclusion of painful thoughts or memories from awareness, which is not demonstrated in this case.

5. A male employee who is assessed weekly in the employee clinic for blood pressure because of a history of hypertension tells the nurse that he is so upset with one of his co-workers that he would like to shoot him. What action should the nurse take first?

Correct answer: A

Rationale: Determining if the client has access to a weapon is critical for immediate safety and to prevent potential harm.

Similar Questions

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A male client with schizophrenia tells the nurse that the voices he hears are saying, 'You must kill yourself.' To assist the client in coping with these thoughts, which response is best for the nurse to provide?
A client with obsessive-compulsive disorder (OCD) spends hours checking and rechecking the locks on the doors. What is the best nursing intervention?
A client with depression is prescribed an SSRI. The client asks, 'Why do I need to take this medication every day?' What is the best response by the nurse?
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