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 interven
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HESI Mental Health Practice Questions

1. 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.

2. During a manic episode, what is the most appropriate nursing intervention for a client with bipolar disorder?

Correct answer: B

Rationale: During a manic episode, individuals with bipolar disorder often experience excessive energy and impulsivity. Providing a quiet and structured environment is crucial to help manage these symptoms. This intervention promotes stability, reduces overstimulation, and supports the client in regaining control over their behaviors. Choices A and C may exacerbate impulsivity and overstimulation, while choice D does not address the need for environmental structure and may not be effective in managing manic symptoms.

3. A client states that she hears God's voice telling her that she has sinned and needs to punish herself. Which response by the LPN/LVN is most important?

Correct answer: B

Rationale: The most important response by the LPN/LVN is to encourage the client to communicate with staff when they feel the need to punish themselves. This approach can help assess the risk of self-harm and enable appropriate intervention. Choice A focuses more on the method of punishment rather than encouraging help-seeking behavior. Choice C seeks specific details about the perceived wrongdoing rather than addressing the immediate concern of self-punishment. Choice D, discussing strengths, does not directly address the client's current distress and potential self-harm risk.

4. 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.

5. A client with schizophrenia is admitted to the psychiatric care unit for aggressive behavior, auditory hallucinations, and potential for self-harm. The client has not been taking medications as prescribed and insists that the food has been poisoned and refuses to eat. What intervention should the RN implement?

Correct answer: D

Rationale: The correct intervention is to provide the client with food in unopened containers. This approach can help alleviate the client's fear of poisoning and encourage eating. Choice A may not address the client's specific fear and may be perceived as dismissive. Choice B, while providing information about symptoms of schizophrenia, does not address the immediate issue of the client's refusal to eat due to the fear of poisoning. Choice C of obtaining an order for tube feeding is premature and invasive before exploring less restrictive options.

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