HESI LPN
HESI Mental Health Practice Questions
1. An elderly female client with advanced dementia is admitted to the hospital with a fractured hip. The client repeatedly tells the staff, 'Take me home. I want my Mommy.' Which response is best for the nurse to provide?
- A. Orient the client to the time, place, and person.
- B. Tell the client that the nurse is there and will help her.
- C. Remind the client that her mother is no longer living.
- D. Explain the seriousness of her injury and need for hospitalization.
Correct answer: B
Rationale: Those with dementia often refer to home or parents when seeking security and comfort. The nurse should use the techniques of 'offering self' and 'talking to the feelings' to provide reassurance (B). Clients with advanced dementia have permanent physiological changes in the brain (plaques and tangles) that prevent them from comprehending and retaining new information, so choices A, C, and D are likely to be of little use to this client and do not address the emotional needs expressed by the client. Option B acknowledges the client's feelings, offers support, and provides reassurance, which can help comfort the client during this distressing time.
2. A teenaged client, a heroin addict, is admitted to the unit for detoxification. What intervention is most important for the nurse to initiate during the first 24 hours after admission?
- A. Assign the client to a teen support group.
- B. Assess intake and output.
- C. Monitor for wheezing and apnea.
- D. Limit visitors to family members only.
Correct answer: B
Rationale: Assessing intake and output is crucial during the first 24 hours after admission for detoxification. This helps the nurse monitor the client's hydration status and kidney function as the body goes through withdrawal from heroin. Option A is incorrect because joining a support group is beneficial but may not be the priority in the initial phase of detoxification. Option C, monitoring for wheezing and apnea, is important but not the most critical intervention during the first 24 hours. Option D, limiting visitors to family members only, is not directly related to the immediate needs of assessing intake and output.
3. A 65-year-old female client complains to the nurse that recently she has been hearing voices. What question should the nurse ask this client first?
- A. Do you have problems with hallucinations?
- B. Are you ever alone when you hear the voices?
- C. Has anyone in your family had hearing problems?
- D. Do you see things that others cannot see?
Correct answer: B
Rationale: The nurse should first ask if the client is ever alone when she hears the voices. This question helps differentiate between potential auditory hallucinations and other causes like hearing loss. Choice A is not the best first question as it assumes the client is experiencing hallucinations without exploring other possibilities. Choice C is irrelevant to the immediate concern of hearing voices. Choice D pertains to visual hallucinations which are not described in the client's complaint of hearing voices.
4. The RN is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? (select one that does not apply)
- A. Purchase a gun to use for protection.
- B. Keep quiet and calm.
- C. Take a self-defense course that retaliates against the abuser with injury.
- D. Have a bag ready that has extra clothes for self and children.
Correct answer: C
Rationale: Taking a self-defense course that retaliates against the abuser with injury can escalate the level of violence and is not recommended in a safety plan for a victim of intimate partner violence. The correct strategies include establishing a code, having a bag ready, and planning an escape route, which enhance safety without increasing the risk of harm.
5. A LPN/LVN is preparing to care for a dying client, and several family members are at the client's bedside. Select the therapeutic techniques that the nurse would use when communicating with the family. Select one that does not apply.
- A. Discourage reminiscing
- B. Make decisions for the family
- C. Encourage expression of feelings, concerns, and fears
- D. Explain everything that is happening to all family members
Correct answer: B
Rationale: Encouraging the expression of feelings, concerns, and fears is a therapeutic technique that helps the family cope with the situation and express their emotions. This approach fosters trust and emotional release. Making decisions for the family is not appropriate because it takes away their autonomy and control during a difficult time. Discouraging reminiscing may hinder the family's coping mechanisms by discouraging them from sharing memories and finding comfort in the past. Explaining everything that is happening to all family members promotes transparency and understanding, which can help reduce anxiety and fear.
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