HESI LPN
Mental Health HESI 2023
1. The nurse is planning the care for a 32-year-old male client with acute depression. Which nursing intervention would be best in helping this client deal with his depression?
- A. Ensure that the client's day is filled with group activities.
- B. Assist the client in exploring feelings of shame, anger, and guilt.
- C. Allow the client to initiate and determine activities of daily living.
- D. Encourage the client to explore the rationale for his depression.
Correct answer: B
Rationale: Assisting the client in exploring feelings of shame, anger, and guilt (B) is the most appropriate intervention for acute depression as it helps address core emotions that may be contributing to the condition. Focusing on these emotions can aid the client in processing and coping with their feelings. Ensuring that the client's day is filled with group activities (A) might overwhelm the client, as they may not be ready for social interactions during this sensitive time. Allowing the client to initiate and determine activities of daily living (C) is more suitable for chronic cases where the client needs to regain autonomy. Encouraging the client to explore the rationale for his depression (D) is less effective in acute cases, as the focus should be on immediate emotional support and understanding rather than cognitive analysis.
2. A client is recovering from a right-sided mastectomy and is concerned about lymphedema. What should the nurse include in the discharge teaching to minimize this risk?
- A. Encourage wearing tight clothing on the affected arm.
- B. Advise against lifting heavy objects with the affected arm.
- C. Recommend the client sleep on the affected side.
- D. Suggest frequent massage of the affected arm.
Correct answer: B
Rationale: The correct answer is B: Advise against lifting heavy objects with the affected arm. Lifting heavy objects with the affected arm can increase the risk of lymphedema. It is important for clients to avoid activities that strain the affected arm to minimize the risk of developing lymphedema. Choices A, C, and D are incorrect because wearing tight clothing on the affected arm, sleeping on the affected side, and frequent massage of the affected arm can potentially worsen lymphedema or impede the recovery process. Tight clothing can impede lymphatic flow, sleeping on the affected side can restrict circulation, and frequent massage can exacerbate swelling in the arm.
3. A client with major depression who is taking fluoxetine calls the psychiatric clinic reporting being more agitated, irritable, and anxious than usual. Which intervention should the nurse implement?
- A. Tell the client to have a complete blood count (CBC) drawn
- B. Instruct the client to seek medical attention immediately
- C. Encourage them to take the medication at night with a snack
- D. Explain that these are common side effects of the medication
Correct answer: B
Rationale: Increased agitation, irritability, and anxiety can be signs of serotonin syndrome or other serious side effects, not common side effects of fluoxetine. Instructing the client to seek medical attention immediately is crucial to address any potential serious adverse reactions. Option A is unnecessary as a CBC would not address the symptoms described. Option C is not the priority when serious side effects are suspected. Option D is incorrect as these symptoms should not be dismissed as common side effects.
4. A charge nurse is assigning tasks to a nurse and assistive personnel for a group of clients. Which of the following tasks should the charge nurse delegate to the AP?
- A. Report ABG results to the provider
- B. Instruct a client about how to use an incentive spirometer
- C. Administer an enteral feeding to a client who has an established gastrostomy tube
- D. Monitor the color of a client’s urinary output
Correct answer: D
Rationale: The correct answer is D because monitoring the color of a client's urinary output is a task that can be safely delegated to assistive personnel. This task involves basic observation and does not require specialized nursing knowledge or skills. Choice A is incorrect because reporting ABG results to the provider requires interpretation and critical thinking skills typically performed by a nurse. Choice B is incorrect as instructing a client about how to use an incentive spirometer involves educating and assessing the client, which is a nursing responsibility. Choice C is incorrect as administering enteral feeding to a client with a gastrostomy tube requires nursing expertise to ensure proper technique and monitoring for complications.
5. A male client approaches the nurse with an angry expression on his face and raises his voice, saying, 'My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out!' The nurse recognizes that the client is using which defense mechanism?
- A. Denial
- B. Projection
- C. Rationalization
- D. Splitting
Correct answer: B
Rationale: The correct answer is B: Projection. In this scenario, the client is projecting his own feelings of anger and selfishness onto his roommate. Projection is a defense mechanism where individuals attribute their own unacceptable thoughts, feelings, and motives to another person. Choices A, C, and D are incorrect. Denial is refusing to acknowledge an aspect of reality or experience. Rationalization is providing logical-sounding reasons to justify unacceptable behaviors or feelings. Splitting is seeing individuals as all good or all bad, with no middle ground.