HESI LPN
HESI Mental Health
1. Within several days of hospitalization, a client is repeatedly washing the top of the same table. Which initial intervention is best for the nurse to implement to help the client cope with anxiety related to this behavior?
- A. Administer a prescribed PRN antianxiety medication.
- B. Assist the client in identifying stimuli that precipitate the ritualistic activity.
- C. Allow time for the ritualistic behavior, then redirect the client to other activities.
- D. Teach the client relaxation and thought-stopping techniques.
Correct answer: C
Rationale: Initially, the nurse should allow time for the ritualistic behavior (C) to prevent anxiety. Administering an antianxiety medication (A) may help reduce the client's anxiety temporarily but will not address the underlying issue of ineffective coping mechanisms leading to the behavior. While assisting the client in identifying triggers (B) is important for long-term therapy, the immediate focus should be on managing the behavior. Teaching relaxation and thought-stopping techniques (D) is beneficial but might be more effective once the client is more stable and receptive to learning new coping strategies.
2. A nurse is providing discharge teaching to a client with schizophrenia who is prescribed clozapine (Clozaril). Which information should the nurse include?
- A. You need to come in for regular blood tests.
- B. This medication can cause weight loss.
- C. You can stop taking this medication once you feel better.
- D. Avoid foods high in tyramine while on this medication.
Correct answer: A
Rationale: The correct answer is A: 'You need to come in for regular blood tests.' Clozapine can cause agranulocytosis, a potentially life-threatening condition, so regular blood tests are required to monitor the client's white blood cell count. Choice B is incorrect because clozapine is associated with weight gain, not weight loss. Choice C is incorrect because the client should never stop taking clozapine abruptly due to the risk of withdrawal symptoms and symptom relapse. Choice D is incorrect because avoiding foods high in tyramine is typically associated with MAOIs, not clozapine.
3. A client with schizophrenia is being treated with haloperidol (Haldol) and begins to exhibit symptoms of tardive dyskinesia. What is the nurse's priority action?
- A. Continue the medication and monitor for worsening symptoms.
- B. Administer the next dose of haloperidol with food.
- C. Report the symptoms to the healthcare provider immediately.
- D. Educate the client about the side effects of haloperidol.
Correct answer: C
Rationale: The correct answer is to report the symptoms to the healthcare provider immediately. Tardive dyskinesia is a serious side effect of antipsychotic medications, including haloperidol. Prompt reporting is crucial to evaluate the need for medication adjustment or change in treatment. Continuing the medication without intervention (choice A) can worsen the symptoms. Administering the next dose (choice B) is not appropriate when tardive dyskinesia is suspected. Educating the client (choice D) is important but not the priority when dealing with acute symptoms of tardive dyskinesia.
4. A client with generalized anxiety disorder is being taught about buspirone (BuSpar) by a nurse. Which statement by the client indicates a need for further teaching?
- A. I should take this medication on an empty stomach.
- B. It may take several weeks before I feel better.
- C. This medication does not cause dependence.
- D. I can drink alcohol while taking this medication.
Correct answer: D
Rationale: The statement 'I can drink alcohol while taking this medication' (D) indicates a need for further teaching. Clients should avoid alcohol while taking buspirone because it can increase the risk of side effects such as dizziness and drowsiness. Choices A, B, and C are correct statements regarding buspirone and do not require further teaching.
5. 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.
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