HESI LPN
HESI Mental Health Practice Exam
1. When caring for a client with borderline personality disorder in a psychiatric unit, what is the most therapeutic nursing intervention?
- A. Set clear and consistent boundaries for the client.
- B. Allow the client to vent their feelings without interruption.
- C. Encourage the client to participate in group therapy.
- D. Provide the client with frequent reassurance and support.
Correct answer: A
Rationale: Setting clear and consistent boundaries is the most therapeutic nursing intervention when caring for a client with borderline personality disorder. This approach provides structure, promotes predictability, and helps prevent manipulative behaviors. By establishing boundaries, the nurse can maintain a safe therapeutic relationship with the client. Allowing the client to vent their feelings without interruption (Choice B) may not always be beneficial, as it could reinforce maladaptive behaviors. Encouraging participation in group therapy (Choice C) can be helpful but setting boundaries is more critical for individualized care. Providing the client with frequent reassurance and support (Choice D) may not address the underlying issues and can contribute to dependency rather than fostering independence and coping skills.
2. The RN documents the mental status of a female client who has been hospitalized for several days by court order. The client states 'I don't need to be here,' and tells the RN that she believes that the TV talks to her. The RN should document these assessment statements in which section of the mental status exam?
- A. Insight and judgment.
- B. Mood and affect.
- C. Remote memory.
- D. Level of concentration.
Correct answer: A
Rationale: The correct answer is A: Insight and judgment. The client's statements indicate her lack of insight into her need for hospitalization ('I don't need to be here') and the presence of a delusion (believing that the TV talks to her). These statements reflect the client's insight into her condition and judgment. This information is crucial for assessing the client's understanding of her situation and decision-making capacity. Choice B, Mood and affect, focuses on the client's emotional state rather than her insight and judgment. Choice C, Remote memory, pertains to the ability to recall past events, which is not the primary focus of the client's statements. Choice D, Level of concentration, is not directly related to the client's statements about her need for hospitalization and the delusional belief about the TV.
3. A male client with schizophrenia who is taking fluphenazine decanoate (Prolixin decanoate) is being discharged in the morning. A repeat dose of medication is scheduled for 20 days after discharge. The client tells the nurse that he is going on vacation in the Bahamas and will return in 18 days. Which statement by the client indicates a need for health teaching?
- A. "When I return from my tropical island vacation, I will go to the clinic to get my Prolixin injection."
- B. "While I am on vacation and when I return, I will not consume any alcohol-containing food or beverages."
- C. "I will inform the healthcare provider if I develop a sore throat or flu-like symptoms."
- D. "I will maintain my daily intake of benztropine mesylate (Cogentin)."
Correct answer: A
Rationale: Photosensitivity is a side effect of Prolixin, and a vacation in the Bahamas (with its tropical island climate) increases the client's risk of experiencing this side effect. Therefore, the client should be advised to avoid direct sun exposure. Choice A indicates a need for health teaching as the client plans to return from vacation in 18 days, which is earlier than the scheduled dose of Prolixin at 20 days after discharge. Choices B, C, and D demonstrate accurate knowledge. Choice B is important because alcohol can interact with Prolixin. Choice C is relevant as it mentions signs of agranulocytosis, a potential side effect of Prolixin. Choice D is correct as benztropine mesylate is used to prevent extrapyramidal symptoms associated with Prolixin.
4. A client is admitted to a medical nursing unit with a diagnosis of acute blindness. Many tests are performed, and there seems to be no organic reason why this client cannot see. The client became blind after witnessing a hit-and-run car accident, when a family of three was killed. A LPN/LVN suspects that the client may be experiencing a:
- A. Psychosis
- B. Repression
- C. Conversion Disorder
- D. Dissociative Disorder
Correct answer: C
Rationale: In this scenario, the client's acute blindness without any organic cause following a traumatic event indicates a case of Conversion Disorder. Conversion Disorder involves the manifestation of physical symptoms due to psychological stressors. Psychosis (choice A) involves a loss of contact with reality, which is not evident here. Repression (choice B) is a defense mechanism that involves unconsciously blocking out thoughts. Dissociative Disorder (choice D) involves disruptions in memory, awareness, identity, or perception, which is not the primary issue in this case.
5. During a manic episode, what is the most appropriate nursing intervention for a client with bipolar disorder?
- A. Allow the client to engage in any activities they choose.
- B. Provide a quiet and structured environment.
- C. Encourage the client to participate in group activities.
- D. Allow the client to take short naps during the day.
Correct answer: B
Rationale: During a manic episode, individuals with bipolar disorder often experience excessive energy and impulsivity. Providing a quiet and structured environment is crucial to help manage these symptoms. This intervention promotes stability, reduces overstimulation, and supports the client in regaining control over their behaviors. Choices A and C may exacerbate impulsivity and overstimulation, while choice D does not address the need for environmental structure and may not be effective in managing manic symptoms.
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