which action is most important for the nurse to implement during the initial interview for a client who is admitted to the mental health unit
Logo

Nursing Elites

HESI LPN

HESI Mental Health 2023

1. Which action is most important for the nurse to implement during the initial interview for a client who is admitted to the mental health unit?

Correct answer: A

Rationale: Establishing rapport is the most important action during the initial interview for a client admitted to the mental health unit. Building rapport helps create a trusting relationship between the nurse and the client, which is essential for effective communication and the success of the therapeutic relationship. Choice B, determining the client's ability to communicate effectively, is important but secondary to establishing rapport. Choice C, reflecting on previous psychiatric interviews, is not as critical during the initial interview with a new client. Choice D, ensuring data collection and recording in a systematic sequence, is important but comes after establishing rapport to foster a therapeutic environment.

2. A LPN/LVN is performing a follow-up teaching session with a client discharged 1 month ago. The client is taking fluoxetine (Prozac). What information would be important for the nurse to obtain during this client visit regarding the side effects of the medication?

Correct answer: B

Rationale: The correct answer is B: 'Gastrointestinal dysfunctions.' Fluoxetine commonly causes gastrointestinal side effects such as nausea, diarrhea, or constipation. These symptoms can significantly impact the client's quality of life and adherence to the medication regimen. Monitoring gastrointestinal issues is crucial for the nurse to ensure the client's well-being and optimize treatment outcomes. Choices A, C, and D are incorrect because cardiovascular symptoms, problems with mouth dryness, and problems with excessive sweating are not typically associated with fluoxetine use and are less likely to be a focus of concern during this client visit.

3. A client who has just been sexually assaulted is calm and quiet. The nurse analyzes this behavior as indicating which defense mechanism?

Correct answer: A

Rationale: The correct answer is A: Denial. In this situation, the client's calm and quiet demeanor after a traumatic event like sexual assault may indicate denial, a defense mechanism where the individual refuses to acknowledge the reality of the distressing event. Choice B, Projection, involves attributing one's thoughts or feelings to others. Choice C, Rationalization, is a defense mechanism where logical reasoning is used to justify behaviors or feelings. Choice D, Intellectualization, is a defense mechanism where excessive reasoning or logic is used to avoid uncomfortable emotions.

4. The client with schizophrenia believes the news commentator is her lover and speaks to her. What is the best response for the nurse to make?

Correct answer: A

Rationale: The correct response is to ask the client what she believes the news commentator said, as it helps the nurse assess the client's perception and delve into her delusions without being confrontational. Choice B is not helpful in addressing the client's delusions. Choice C jumps to conclusions about potential harm without assessing the client's beliefs. Choice D is dismissive and does not address the client's reality.

5. A client with schizophrenia is prescribed olanzapine (Zyprexa). What is the most important side effect for the nurse to monitor?

Correct answer: B

Rationale: The correct answer is B: Weight gain. Olanzapine (Zyprexa) is known to cause significant weight gain in patients. This side effect is crucial to monitor because it can lead to metabolic syndrome, diabetes, and cardiovascular issues. Monitoring the client's weight regularly and providing appropriate dietary guidance is essential. Hypotension (choice A), dry mouth (choice C), and tachycardia (choice D) are not commonly associated with olanzapine use and are not the primary side effects to monitor in this case.

Similar Questions

An adult male client who was admitted to the mental health unit yesterday tells the nurse that microchips were planted in his head for military surveillance of his every move. Which response is best for the nurse to provide?
A male client with borderline personality disorder is manipulative and consistently attempts to violate unit rules. What is the best approach for the nurse to take?
A 35-year-old male client on the psychiatric unit of a general hospital believes that someone is trying to poison him. The nurse understands that a client's delusions are most likely related to his
The LPN/LVN is caring for a client who has been prescribed a monoamine oxidase inhibitor (MAOI) for depression. Which statement by the client indicates a need for further teaching?
A nurse notes that a depressed female client has been more withdrawn and less communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?

Access More Features

HESI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses