the nurse suspects child abuse when assessing a 3 year old boy and noticing several small round burns on his legs and trunk that might be the result o
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Mental Health HESI Practice Questions

1. The nurse suspects child abuse when assessing a 3-year-old boy and noticing several small, round burns on his legs and trunk that might be the result of cigarette burns. Which parental behavior provides the greatest validation for such suspicions?

Correct answer: D

Rationale: (D) provides the most validation for suspecting child abuse. The parent's explanation (subjective data) that the child was burned in a house fire is incompatible with the objective data observed by the nurse (small, round burns on the legs and trunk). (A) relies on subjective data, and the child's explanation might not accurately reflect the situation due to various factors like age or fear. The apparent lack of concern from the parents (B) is inconclusive as the nurse's interpretation of their reaction could be subjective. While parental anxiety (C) could hint at potential child abuse, it's important to note that most parents would naturally be anxious about their child's hospitalization, making it a less definitive indicator compared to the inconsistency in the explanation provided by the parents in option (D).

2. At a support meeting of parents of a teenager with polysubstance dependency, a parent states, 'Each time my son tries to quit taking drugs, he gets so depressed that I'm afraid he will commit suicide.' The nurse's response should be based on which information?

Correct answer: C

Rationale: The correct response in this situation should focus on the connection between feelings of depression and drug abuse. Choice A is incorrect because addiction is treatable, not incurable. Choice B is incorrect as tolerance does not directly cause depression. Choice D is not the best response as the parent's concern is about the son's depression leading to suicidal thoughts, not just the withdrawal process.

3. The nurse should hold the next scheduled dose of a client's haloperidol (Haldol) based on which assessment finding(s)?

Correct answer: D

Rationale: A fever (D) may indicate neuroleptic malignant syndrome (NMS), a potentially fatal complication of antipsychotics. The healthcare provider should be contacted before administering the next dose of Haldol. Dizziness when standing (A), shuffling gait and hand tremors (B), and urinary retention (C) are all adverse effects of Haldol that, while concerning, do not pose immediate life-threatening risks compared to the potential severity of NMS indicated by a fever.

4. A client with bipolar disorder is being discharged with a prescription for lithium. What is the most important instruction the nurse should provide?

Correct answer: B

Rationale: The correct answer is to instruct the client to drink plenty of fluids, especially during hot weather. Maintaining adequate hydration is crucial for clients taking lithium as dehydration can lead to lithium toxicity. Choice A is incorrect because while it is important to monitor sodium intake, staying hydrated is more critical. Choice C is incorrect as lithium is usually recommended to be taken with food to reduce stomach upset. Choice D is also important but not the most crucial instruction compared to ensuring proper hydration.

5. A client in the mental health unit believes that the food is being poisoned. What intervention(s) would be helpful when attempting to encourage the client to eat? Select one that does not apply.

Correct answer: B

Rationale: Using open-ended questions and focusing on the client's self-disclosure about food preferences can help build rapport and trust with the client, encouraging them to eat. Identifying the reasons the client has for not wanting to eat can provide insights into their concerns. However, offering opinions about the necessity for adequate nutrition may come across as imposing views on the client, potentially leading to resistance. This approach may not be as effective in encouraging the client to eat as it could create a power dynamic that hinders the therapeutic relationship.

Similar Questions

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An 86-year-old female client with Alzheimer's disease is wandering the busy halls of the extended care facility and asks the nurse, 'Where should I stand for the parade?' Which response is best for the nurse to provide?
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In the described scenario, a manic client threatens a nurse with physical violence after being told they cannot have a stripper perform. What is the most appropriate action for the LPN/LVN to take?
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