HESI LPN
HESI Mental Health 2023
1. The nurse should hold the next scheduled dose of a client's haloperidol (Haldol) based on which assessment finding(s)?
- A. Dizziness when standing.
- B. Shuffling gait and hand tremors.
- C. Urinary retention.
- D. Fever of 102°F.
Correct answer: D
Rationale: A fever (D) may indicate neuroleptic malignant syndrome (NMS), a potentially fatal complication of antipsychotics. The healthcare provider should be contacted before administering the next dose of Haldol. Dizziness when standing (A), shuffling gait and hand tremors (B), and urinary retention (C) are all adverse effects of Haldol that, while concerning, do not pose immediate life-threatening risks compared to the potential severity of NMS indicated by a fever.
2. 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.
3. An adult male client who was admitted to the mental health unit yesterday tells the nurse that microchips were planted in his head for military surveillance of his every move. Which response is best for the nurse to provide?
- A. You are in the hospital, and I am the nurse caring for you
- B. It must be difficult for you to control your anxious feelings
- C. Go to occupational therapy and start a project
- D. You are not in a war area now; this is the United States
Correct answer: C
Rationale: Delusions often generate fear and isolation, so the nurse should help the client participate in activities that avoid focusing on the false belief and encourage interaction with others.
4. What is the most therapeutic nursing response for a client with borderline personality disorder who engages in self-mutilating behavior?
- A. Encourage the client to stop hurting themselves.
- B. Discuss what the client was feeling before self-harming.
- C. Inform the client that the behavior will be reported to their doctor.
- D. Ask the client why they hurt themselves.
Correct answer: B
Rationale: The most therapeutic nursing response for a client with borderline personality disorder engaging in self-mutilating behavior is to discuss what the client was feeling before self-harming. This approach helps in exploring the underlying triggers and emotions that lead to self-harm. Option A is directive and may come across as judgmental rather than empathetic. Option C can lead to feelings of betrayal and breach of trust. Option D is a closed-ended question that may not facilitate open communication or exploration of emotions.
5. A client with borderline personality disorder tells the nurse, 'You're the only one who understands me. The other nurses don't care about me.' Which response by the nurse is most appropriate?
- A. Why do you feel that way about the other nurses?
- B. The other nurses care about you too.
- C. I am here to help you just like the other nurses.
- D. Let's talk about why you feel this way.
Correct answer: C
Rationale: The most appropriate response is 'I am here to help you just like the other nurses' (C). This response sets boundaries and avoids reinforcing the client's splitting behavior, which is common in borderline personality disorder. Choices A and D may unintentionally reinforce the splitting by focusing on the negative perception of other nurses. Choice B might be perceived as dismissive because it contradicts the client's feelings of being understood only by the nurse.
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