HESI LPN
HESI Mental Health
1. A 52-year-old male client in the intensive care unit who has been oriented suddenly becomes disoriented and fearful. Assessment of vital signs and other physical parameters reveal no significant change, and the nurse formulates the diagnosis, 'Confusion related to ICU psychosis.' Which intervention would be best to implement?
- A. Move all machines away from the client's immediate area.
- B. Attempt to allay the client's fears by explaining the etiology of his condition.
- C. Cluster care so that brief periods of rest can be scheduled during the day.
- D. Extend visitation times for family and friends.
Correct answer: C
Rationale: In critical care environments, stressors can lead to isolation and confusion. Providing the client with scheduled rest periods (C) can help alleviate these symptoms. Moving all machines away (A) is impractical as they are often essential. Explaining the condition (B) may not be effective during acute confusion. Extending visitation times (D) can be overwhelming for the client in the ICU.
2. A client with generalized anxiety disorder is being treated with lorazepam (Ativan). What is the most important teaching point for the LPN/LVN to reinforce?
- A. Take the medication on an empty stomach.
- B. Avoid drinking alcohol while taking this medication.
- C. This medication may cause drowsiness, so avoid driving.
- D. You can stop taking the medication once you feel better.
Correct answer: B
Rationale: The most important teaching point for the LPN/LVN to reinforce is to avoid drinking alcohol while taking lorazepam (Ativan). Alcohol can enhance the sedative effects of lorazepam, increasing the risk of severe side effects and complications. Choice A is incorrect because lorazepam can be taken with or without food. Choice C is not the most critical teaching point, although it is essential to avoid activities that require mental alertness until the effects of the medication are known. Choice D is incorrect because abruptly stopping lorazepam can lead to withdrawal symptoms and should only be done under medical supervision.
3. A client with schizophrenia is experiencing auditory hallucinations. What is the most appropriate nursing intervention?
- A. Encourage the client to focus on reality-based activities.
- B. Tell the client that the voices are not real.
- C. Ask the client to describe the voices he hears.
- D. Encourage the client to interact with others who are not experiencing hallucinations.
Correct answer: A
Rationale: The most appropriate nursing intervention for a client with schizophrenia experiencing auditory hallucinations is to encourage the client to focus on reality-based activities. This intervention helps redirect their attention away from hallucinations, promoting engagement with the environment. Choice B is incorrect as telling the client that the voices are not real may invalidate their experiences and worsen the therapeutic relationship. Choice C may increase the client's distress by focusing on the hallucinations. Choice D might not be helpful as interacting with others who are not experiencing hallucinations may not address the client's current needs.
4. An adult female client tells the nurse that though she is afraid her abusive boyfriend might one day kill her, she keeps hoping that he will change. What action should the nurse take first?
- A. Discuss treatment options for abusive partners.
- B. Explore the client's readiness to discuss the situation.
- C. Determine the frequency and type of client's abuse.
- D. Report the finding to the police department.
Correct answer: B
Rationale: Exploring the client's readiness to discuss the situation is the correct first step. It allows the nurse to assess the client's emotional state, willingness to seek help, and readiness to address the abusive relationship. This approach helps build trust and rapport with the client, paving the way for further interventions. Discussing treatment options for abusive partners (Choice A) may be premature and not well-received if the client is not ready to address the situation. Determining the frequency and type of abuse (Choice C) is important but not the immediate priority compared to assessing the client's readiness to talk. Reporting the finding to the police (Choice D) should be done if there is an immediate threat to the client's safety, but exploring the client's readiness to discuss the situation should be the initial step to provide support and intervention.
5. A client with obsessive-compulsive disorder (OCD) spends several hours a day washing his hands. What is the best nursing intervention?
- A. Restrict the client's access to soap and water.
- B. Encourage the client to discuss their compulsions.
- C. Allow the client to continue the behavior until ready to stop.
- D. Schedule activities that distract the client from hand-washing.
Correct answer: B
Rationale: Encouraging the client to discuss their compulsions is the best nursing intervention when caring for a client with OCD who spends excessive time on hand-washing. This approach can help the client identify underlying anxieties and triggers associated with the compulsive behavior. Restricting access to soap and water (Choice A) can lead to increased anxiety and worsen the obsession. Allowing the client to continue the behavior (Choice C) can perpetuate the compulsive cycle. Scheduling distracting activities (Choice D) may provide temporary relief but does not address the root cause of the behavior.
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