HESI LPN
HESI Mental Health
1. A nurse is caring for a client with major depressive disorder who is withdrawn and refuses to participate in group activities.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.
2. A client diagnosed with paranoid schizophrenia is still withdrawn, unkempt, and unmotivated to get out of bed. A mental health aide asks the nurse why the client is this way after being on fluphenazine (Prolix) 10 mg for 7 days. The LPN/LVN should tell the health aide:
- A. Prolixin is the most effective with positive symptoms of schizophrenia.
- B. The client will be less withdrawn and unmotivated when the Prolixin takes effect.
- C. The client's Prolixin dose probably needs to be increased again.
- D. Lack of motivation is a common side effect of the Prolixin.
Correct answer: A
Rationale: Prolixin is more effective with positive symptoms of schizophrenia, such as hallucinations and delusions, rather than negative symptoms like withdrawal and lack of motivation.
3. A male client with alcohol dependence is admitted for detoxification. The nurse knows that which assessment finding is indicative of alcohol withdrawal?
- A. Bradycardia
- B. Hypotension
- C. Tremors
- D. Hyperglycemia
Correct answer: C
Rationale: Tremors are a common sign of alcohol withdrawal. The central nervous system becomes hyperexcitable due to the suppression caused by chronic alcohol intake. Tremors are a manifestation of this hyperexcitability and are a key indicator of alcohol withdrawal. Bradycardia and hypotension are more commonly associated with conditions like shock or severe dehydration rather than alcohol withdrawal. Hyperglycemia is not a typical finding in alcohol withdrawal; instead, hypoglycemia is more commonly seen due to the effects of alcohol on glucose metabolism.
4. A 35-year-old male client on the psychiatric ward 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
- A. early childhood experiences involving authority issues.
- B. anger about being hospitalized.
- C. low self-esteem.
- D. phobic fear of food.
Correct answer: C
Rationale: The correct answer is C: low self-esteem. Delusions of persecution, like being poisoned, are often rooted in underlying issues of low self-esteem and trust. Option A is incorrect because the delusion is not necessarily related to early childhood experiences involving authority issues. Option B is incorrect as there is no information provided that suggests the client's delusion is driven by anger about being hospitalized. Option D is incorrect as the delusion is about being poisoned, not a phobic fear of food.
5. A 25-year-old female client has been particularly restless, and the nurse finds her trying to leave the psychiatric unit. She tells the nurse, 'Please let me go! I must leave because the secret police are after me.' Which response is best for the nurse to make?
- A. No one is after you; you're safe here.
- B. You'll feel better after you have rested.
- C. I know you must feel lonely and frightened.
- D. Come with me to your room, and I will sit with you.
Correct answer: D
Rationale: In this scenario, the best response for the nurse is to offer presence and a safe environment without validating the delusion or arguing with the client. By inviting the client to the room and offering to sit with her, the nurse is providing support and reassurance. Choice A is incorrect because directly denying the client's belief may escalate the situation. Choice B is inappropriate as it dismisses the client's concerns without addressing the underlying issue. Choice C acknowledges the client's feelings but does not provide immediate support or safety, unlike Choice D which offers both.
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