HESI LPN
HESI Mental Health 2023
1. A client with schizophrenia is experiencing delusions. What is the most appropriate nursing intervention?
- A. Encourage the client to explore the delusions in depth.
- B. Tell the client that the delusions are not real.
- C. Explore the underlying meaning of the delusions.
- D. Distract the client from the delusions and focus on reality.
Correct answer: D
Rationale: The most appropriate nursing intervention for a client with schizophrenia experiencing delusions is to distract the client from the delusions and focus on reality. Encouraging the client to explore the delusions in depth (Choice A) may worsen the delusions. Telling the client that the delusions are not real (Choice B) can lead to confrontation and disbelief. Exploring the underlying meaning of the delusions (Choice C) may not be effective during acute episodes of delusions; hence, distracting the client and refocusing on reality is the most suitable intervention.
2. Select the nursing interventions for a hospitalized client with mania who is exhibiting manipulative behavior. Select one intervention that does not apply.
- A. Communicate expected behaviors to the client
- B. Ensure that the client knows that he or she is not in charge of the nursing unit
- C. Assist the client in identifying ways of setting limits on personal behaviors
- D. Follow through about the consequences of behavior in a non-punitive manner
Correct answer: B
Rationale: The correct answer is B. Ensuring that the client knows they are not in charge of the nursing unit is not a helpful nursing intervention for managing manipulative behavior in a client with mania. Communicating expected behaviors, assisting with limit-setting, and following through on consequences in a non-punitive manner are more appropriate interventions to address manipulative behavior.
3. A nurse is caring for a client who is experiencing withdrawal symptoms from opioid addiction. What is the priority nursing intervention?
- A. Monitor for signs of respiratory depression.
- B. Administer methadone as prescribed.
- C. Provide a calm and quiet environment.
- D. Encourage fluid intake to prevent dehydration.
Correct answer: A
Rationale: The correct answer is A: Monitor for signs of respiratory depression. During opioid withdrawal, the priority is to monitor the client for respiratory depression as it can be life-threatening. Respiratory depression is a serious concern during opioid withdrawal, and prompt recognition and intervention are crucial. Administering methadone as prescribed (Choice B) may be part of the treatment plan but is not the priority in this situation. Providing a calm and quiet environment (Choice C) and encouraging fluid intake to prevent dehydration (Choice D) are important aspects of care but do not take precedence over monitoring for respiratory depression.
4. A male client with borderline personality disorder is manipulative and consistently attempts to violate unit rules. What is the best approach for the nurse to take?
- A. Enforce unit rules consistently with all clients.
- B. Ignore the manipulative behaviors to avoid confrontation.
- C. Provide the client with special privileges to avoid conflict.
- D. Confront the client directly about his behavior.
Correct answer: A
Rationale: The correct approach for the nurse to take when dealing with a male client with borderline personality disorder who is manipulative and consistently attempts to violate unit rules is to enforce unit rules consistently with all clients. By maintaining consistency in enforcing rules, the nurse establishes clear boundaries and provides structure, which are essential for managing manipulative behavior in clients with borderline personality disorder. Ignoring the manipulative behaviors (Choice B) may lead to the reinforcement of negative behaviors. Providing the client with special privileges (Choice C) can enable further manipulation and is not recommended. Confronting the client directly about his behavior (Choice D) may escalate the situation and is less effective than consistent rule enforcement.
5. A client with obsessive-compulsive disorder (OCD) repeatedly washes her hands throughout the day. What is the most therapeutic nursing intervention?
- A. Allow the client to continue the behavior to reduce anxiety.
- B. Encourage the client to talk about the underlying fears.
- C. Restrict the client's access to soap and water.
- D. Schedule a time for the client to perform the ritual.
Correct answer: B
Rationale: Encouraging the client to talk about the underlying fears is the most therapeutic nursing intervention for a client with OCD who repeatedly washes her hands. By discussing the fears, the client can gain insight into the behavior and work towards reducing the compulsion. Choice A is incorrect as allowing the client to continue the behavior can perpetuate the OCD symptoms. Choice C is incorrect as restricting access to soap and water can lead to increased anxiety and distress. Choice D is incorrect as scheduling a time for the client to perform the ritual does not address the underlying fears driving the behavior.
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