HESI LPN
HESI Mental Health
1. The LPN/LVN is caring for a client who has recently been diagnosed with bipolar disorder. The client asks, 'Why do I have to take medication every day?' What is the best response by the nurse?
- A. The medication will help stabilize your mood and prevent mood swings.
- B. You will need to take this medication for the rest of your life.
- C. The medication will help you feel better and more in control of your emotions.
- D. The medication is needed to control your symptoms and help you function better.
Correct answer: A
Rationale: The best response by the nurse is to explain that the medication will help stabilize the client's mood and prevent mood swings. This response provides the client with a clear understanding of how the medication works in managing bipolar disorder. Choice B is not the best response as it may cause unnecessary worry about lifelong medication dependence. Choice C is not as specific in addressing the purpose of the medication for bipolar disorder. Choice D is not as focused on the effect of the medication on mood stabilization, which is crucial in managing bipolar disorder.
2. A female client in an acute care facility has been on antipsychotic medications for the past three days. Her psychotic behaviors have decreased and she has had no adverse reactions. On the fourth day, the client's blood pressure increases, she becomes pale and febrile, and demonstrates muscular rigidity. What action should the nurse initiate?
- A. Place the client on seizure precautions and monitor her frequently.
- B. Take the client's vital signs and notify the physician immediately.
- C. Describe the symptoms to the charge nurse and document them in the client's record.
- D. No action is required at this time as these are known side effects of her medications.
Correct answer: B
Rationale: The correct action for the nurse to initiate is to take the client's vital signs and notify the physician immediately. These symptoms may indicate neuroleptic malignant syndrome, a rare but life-threatening reaction to antipsychotic medications, requiring immediate medical attention. Placing the client on seizure precautions and monitoring her frequently (Choice A) is not the most appropriate action in this situation. Describing the symptoms to the charge nurse and documenting them in the client's record (Choice C) delays prompt medical intervention. Choosing not to take any action (Choice D) is dangerous as the symptoms described suggest a serious condition that needs urgent evaluation and treatment.
3. A female client with anorexia nervosa is admitted to the hospital. What is the priority assessment for the nurse to perform?
- A. Assess the client's body image perception.
- B. Monitor the client's electrolyte levels.
- C. Evaluate the client's exercise habits.
- D. Assess the client's relationship with her family.
Correct answer: B
Rationale: The correct answer is to monitor the client's electrolyte levels. In clients with anorexia nervosa, electrolyte imbalances can lead to serious, potentially life-threatening complications such as cardiac arrhythmias. Assessing body image perception (choice A) is important but not the priority when compared to monitoring electrolyte levels. Evaluating exercise habits (choice C) and assessing the client's relationship with her family (choice D) are also important aspects of care but do not take precedence over monitoring electrolyte levels in a client with anorexia nervosa.
4. A client with generalized anxiety disorder (GAD) is prescribed alprazolam (Xanax). What is the most important teaching point for the nurse to include?
- A. Take this medication at the first sign of anxiety.
- B. Do not stop taking this medication abruptly.
- C. You may experience weight gain while taking this medication.
- D. This medication may cause vivid dreams.
Correct answer: B
Rationale: The most important teaching point for a client prescribed alprazolam is not to stop taking the medication abruptly. Abruptly stopping alprazolam, a benzodiazepine, can lead to withdrawal symptoms. It is crucial to taper off the medication under medical supervision to prevent adverse effects. Choice A is incorrect because taking the medication at the first sign of anxiety is not the key teaching point. Choice C is incorrect because weight gain is not a common side effect of alprazolam. Choice D is incorrect because vivid dreams are not a significant concern compared to the risks of abrupt discontinuation of the medication.
5. A nurse is caring for a client with major depressive disorder who is withdrawn and refuses to participate in group activities. What is the best nursing intervention?
- A. Encourage the client to attend at least one group session.
- B. Respect the client's wish to remain isolated.
- C. Arrange for individual therapy sessions.
- D. Offer the client a list of activities to choose from.
Correct answer: A
Rationale: Encouraging the client to attend at least one group session is the best nursing intervention in this scenario. By gently encouraging participation, the nurse can help the client start to engage with others, which may gradually improve their mood and social interaction. Choice B, respecting the client's wish to remain isolated, may further exacerbate the client's withdrawal and depression by reinforcing avoidance behavior. Choice C, arranging for individual therapy sessions, can be beneficial but may not address the specific need for social interaction. Choice D, offering a list of activities to choose from, does not directly address the client's difficulty in participating in group activities and may not provide the necessary support in overcoming social withdrawal.
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