select the nursing interventions for a hospitalized client with mania who is exhibiting manipulative behavior select one that does not apply
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Nursing Elites

HESI LPN

HESI Mental Health 2023

1. Select the nursing interventions for a hospitalized client with mania who is exhibiting manipulative behavior. Select one intervention that does not apply.

Correct answer: B

Rationale: The correct answer is B. Ensuring that the client knows they are not in charge of the nursing unit is not a helpful nursing intervention for managing manipulative behavior in a client with mania. Communicating expected behaviors, assisting with limit-setting, and following through on consequences in a non-punitive manner are more appropriate interventions to address manipulative behavior.

2. For a female client with major depressive disorder reporting feelings of hopelessness and helplessness, what is the nurse's priority intervention?

Correct answer: C

Rationale: The correct answer is to assess the client's risk for suicide. When a client expresses feelings of hopelessness and helplessness, it indicates a high risk of self-harm or suicide. Therefore, the priority intervention should be to assess the client's safety. Encouraging the client to join a support group (choice A) may be beneficial but not the priority at this time. Referring the client for cognitive-behavioral therapy (CBT) (choice B) and suggesting daily exercise (choice D) are important interventions in managing depression but assessing the risk for suicide takes precedence due to the immediate safety concern.

3. A 45-year-old male client tells the nurse that he used to believe that he was Jesus Christ, but now he knows he is not. Which response is best for the nurse to make?

Correct answer: C

Rationale: Choice C is the best response because it validates the client's experience by acknowledging that others have had similar thoughts when under stress. This response helps normalize the client's past experiences without judgment, fostering a supportive and empathetic environment. Choices A and D may come off as judgmental or confrontational, potentially making the client feel misunderstood or defensive. Choice B, 'I think you're getting well,' does not address the client's past belief or provide the understanding and validation that Choice C offers.

4. A client who is being treated with lithium carbonate for bipolar disorder develops diarrhea, vomiting, and drowsiness. What action should the LPN/LVN take?

Correct answer: B

Rationale: When a client being treated with lithium carbonate for bipolar disorder develops symptoms like diarrhea, vomiting, and drowsiness, it could indicate lithium toxicity. The appropriate action for the LPN/LVN is to notify the healthcare provider immediately of these symptoms before the next administration of the drug. This prompt communication is crucial to ensure that the healthcare provider can assess the situation, adjust the treatment plan if necessary, and prevent potential complications associated with lithium toxicity. Option A is incorrect because administering an antidote should be based on the healthcare provider's assessment. Option C is incorrect as these symptoms are not normal side effects and could indicate a serious issue. Option D is incorrect because refusing to administer the drug without consulting the healthcare provider could delay necessary interventions.

5. The nurse is caring for a client who is experiencing a panic attack. Which intervention should the nurse implement first?

Correct answer: A

Rationale: The priority intervention is to stay with the client and remain calm (A). This provides immediate support and reassurance. Encouraging the client to express their feelings (B) and teaching deep-breathing exercises (C) are important but should come after ensuring the client's immediate safety and comfort. Administering medication (D) might be necessary, but the nurse should first focus on providing a calming presence to help the client feel safe and supported during the panic attack.

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