HESI LPN
HESI Mental Health 2023
1. The nurse is taking a history for a female client who is requesting a routine female exam. Which assessment finding requires follow-up?
- A. Menstruation onset at age 9.
- B. Contraceptive method includes condoms only.
- C. Menstrual cycle occurs every 35 days.
- D. 'Black-out' after one drink last night on a date.
Correct answer: D
Rationale: The correct answer is D. Experiencing a 'black-out' after consuming only one drink is highly unusual and may indicate the client was drugged, necessitating immediate follow-up. Menstruation onset at age 9 and a menstrual cycle occurring every 35 days, although on the outer ranges of 'average,' are within acceptable norms. Relying solely on condoms as a contraceptive method increases the risk of conception.
2. When a client with major depressive disorder expresses feelings of worthlessness and hopelessness, what is the nurse's priority intervention?
- A. Encourage the client to engage in recreational activities.
- B. Suggest the client keep a journal of their thoughts and feelings.
- C. Assess the client for suicidal ideation.
- D. Provide the client with positive affirmations.
Correct answer: C
Rationale: The correct answer is to assess the client for suicidal ideation. When a client expresses feelings of worthlessness and hopelessness, it is crucial to evaluate the risk of self-harm. Encouraging recreational activities (choice A) or suggesting journaling (choice B) may be helpful interventions but assessing for suicidal ideation takes precedence due to the immediate risk of harm. Providing positive affirmations (choice D) is not the priority when safety is a concern.
3. A female victim of sexual assault is being seen in the crisis center. The client states that she still feels 'as though the rape just happened yesterday,' even though it has been a few months since the incident. The appropriate nursing response is which of the following?
- A. You need to try to be realistic. The rape did not just occur.
- B. It will take some time to get over these feelings about your rape.
- C. Tell me more about the incident that causes you to feel like the rape just occurred.
- D. What do you think you can do to alleviate some of your fears about being raped again?
Correct answer: C
Rationale: The correct response is to encourage the client to talk about the event that makes them feel as though the rape just occurred. This approach can help the client process their feelings and experiences, which is crucial in dealing with trauma. Choice A is dismissive and negates the client's feelings, which can be harmful. Choice B, although acknowledging the time needed to heal, does not actively address the client's current feelings. Choice D shifts the focus to future fears rather than addressing the client's current emotional state.
4. A nurse is caring for a client with depression who has been prescribed sertraline (Zoloft). The client reports experiencing nausea. What is the nurse's best response?
- A. "You should stop taking the medication immediately."
- B. "Nausea is a common side effect and usually decreases over time."
- C. "Try taking the medication with food to reduce nausea."
- D. "I will inform the healthcare provider to change your medication."
Correct answer: B
Rationale: The correct answer is B: "Nausea is a common side effect of sertraline, and clients should be reassured that it usually decreases as their body adjusts to the medication." Choice A is incorrect because abruptly stopping the medication without consulting a healthcare provider can be harmful. Choice C is a good suggestion to reduce nausea by taking the medication with food but does not address the temporary nature of the side effect. Choice D is unnecessary at this point since nausea is a common side effect that may improve with time.
5. The nurse is caring for a client who received the first-time electroconvulsive therapy (ECT) a half hour ago. Which action should the nurse implement first?
- A. Offer oral fluids.
- B. Monitor vital signs.
- C. Evaluate ECT effectiveness.
- D. Encourage group participation.
Correct answer: B
Rationale: After a client receives electroconvulsive therapy (ECT), the nurse's priority should be to monitor vital signs. This is important to ensure the client's physical stability and detect any immediate complications post-procedure. Offering oral fluids, evaluating ECT effectiveness, and encouraging group participation are all important aspects of care but monitoring vital signs takes precedence in the immediate post-ECT period.
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