HESI LPN
HESI Mental Health
1. A 30-year-old sales manager tells the nurse, 'I am thinking about a job change. I don't feel like I am living up to my potential.' Which of Maslow's developmental stages is the sales manager attempting to achieve?
- A. Self-Actualization.
- B. Loving and Belonging.
- C. Basic Needs.
- D. Safety and Security.
Correct answer: A
Rationale: The correct answer is A: Self-Actualization. Self-actualization is the highest level of Maslow's development stages, characterized by the desire to fulfill one's full potential and achieve personal growth. In this scenario, the sales manager's statement indicates a need for personal fulfillment and reaching his highest aspirations, aligning with the concept of self-actualization. Choice B, Loving and Belonging, refers to the need for social relationships and support systems. Choice C, Basic Needs, represents the foundation level of Maslow's hierarchy, encompassing physiological needs like food and shelter. Choice D, Safety and Security, pertains to the need for physical and emotional safety.
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 A client diagnosed with paranoid schizophrenia is still withdrawn, unkempt, and unmotivated to get out of bed.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- B. The client will be less withdrawn and unmotivated when the Prolixin takes effect.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 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.
4. A male client with alcohol use disorder is admitted for detoxification. The nurse knows that which symptom is a sign of severe alcohol withdrawal?
- A. Bradycardia
- B. Seizures
- C. Hyperglycemia
- D. Constipation
Correct answer: B
Rationale: Seizures are a sign of severe alcohol withdrawal and can be life-threatening, requiring immediate medical attention. Bradycardia, hyperglycemia, and constipation are not typically associated with severe alcohol withdrawal. Bradycardia is more commonly seen in opioid withdrawal, hyperglycemia could be due to other reasons like uncontrolled diabetes, and constipation is not a typical symptom of severe alcohol withdrawal.
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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