HESI LPN
HESI Mental Health
1. The LPN/LVN is caring for a client with post-traumatic stress disorder (PTSD). Which intervention is most appropriate for the nurse to implement?
- A. Encourage the client to talk about the traumatic event.
- B. Assist the client in developing coping strategies.
- C. Refer the client to a PTSD support group.
- D. Administer prescribed medications to manage symptoms.
Correct answer: B
Rationale: Assisting the client in developing coping strategies is an appropriate intervention for managing PTSD. This approach helps the client build resilience and learn how to effectively cope with symptoms. Choice A, encouraging the client to talk about the traumatic event, may not be appropriate as it can potentially re-traumatize the client. Referring the client to a PTSD support group, as in choice C, can be beneficial but may not be the most immediate intervention. Administering medications, as in choice D, is important in some cases, but focusing on coping strategies should be prioritized as a holistic approach to managing PTSD.
2. A client on a telemetry unit is being cared for by a nurse after a myocardial infarction. The client expresses, 'All this equipment is making me nervous.' Which of the following responses should the nurse make?
- A. 'All of this equipment can be frightening.'
- B. 'The equipment is necessary to monitor your condition.'
- C. 'You should try to ignore the equipment.'
- D. 'Try to relax; the equipment is not harmful.'
Correct answer: A
Rationale: Choice A is the most appropriate response as it acknowledges the client's feelings, showing empathy and understanding. It validates the client's experience, which can help reduce anxiety and build rapport. Choice B provides information but may not address the client's emotional needs. Choice C dismisses the client's concerns and does not offer support. Choice D minimizes the client's feelings and may not effectively address their anxiety.
3. A client with hypertension is prescribed metoprolol. The healthcare provider should monitor the client for which potential side effect?
- A. Bradycardia
- B. Tachycardia
- C. Hyperglycemia
- D. Hyponatremia
Correct answer: A
Rationale: Metoprolol is a beta-blocker that works by slowing the heart rate and reducing blood pressure. One of the potential side effects of metoprolol is bradycardia, which is a slow heart rate. Monitoring for bradycardia is crucial as it can be an adverse effect of this medication.
4. While providing care to a group of patients, which patient should the nurse prioritize seeing first?
- A. A patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea
- B. A bedridden patient with a reddened area on the buttocks who needs to be turned
- C. A patient on bed rest with renal calculi who needs to go to the bathroom
- D. A patient post-knee surgery who needs range of motion exercises
Correct answer: A
Rationale: The nurse should prioritize seeing the patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea first. This patient is at higher risk for deep vein thrombosis due to prolonged bed rest, which can lead to a life-threatening embolus. Chest pain and dyspnea could also indicate a potential pulmonary embolism, which requires immediate assessment and intervention. The other patients, while requiring care, do not present with symptoms that suggest an immediate life-threatening situation, making them lower priority at this time. Therefore, option A is the correct choice as it addresses a potentially critical condition that requires immediate attention.
5. Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room?
- A. Ensure that the knot can be quickly released.
- B. Tie the knot with a double turn or square knot.
- C. Move the ties so the restraints are secured to the side rails.
- D. Ensure that the restraints are snug against the client's wrist.
Correct answer: A
Rationale: The correct action for the nurse to take before leaving the room is to ensure that the knot can be quickly released. Using a half bow knot to attach the client's wrist restraints allows for quick release in case of an emergency. This is crucial for ensuring the safety of the client and complying with restraint policies. Tying the knot with a double turn or square knot (Choice B) would make it difficult to release quickly when needed. Moving the ties so the restraints are secured to the side rails (Choice C) does not address the immediate need for a quick release. Ensuring that the restraints are snug against the client's wrist (Choice D) may not be appropriate if the restraints need to be quickly removed for the client's safety.