HESI LPN
Mental Health HESI 2023
1. A client with schizophrenia receiving haloperidol (Haldol) has a stiff, mask-like facial expression and difficulty speaking. What is the nurse's priority action?
- A. Administer a PRN dose of lorazepam (Ativan).
- B. Encourage the client to perform facial exercises.
- C. Notify the healthcare provider of possible extrapyramidal symptoms (EPS).
- D. Document the findings and continue to monitor the client.
Correct answer: C
Rationale: The correct answer is to notify the healthcare provider of possible extrapyramidal symptoms (EPS). The symptoms described, such as a stiff, mask-like facial expression and difficulty speaking, are indicative of EPS, which can be a serious side effect of haloperidol. It is crucial to involve the healthcare provider immediately to address these symptoms. Administering a PRN dose of lorazepam (Choice A) is not the priority in this situation, as it does not address the underlying cause of EPS. Encouraging the client to perform facial exercises (Choice B) is not appropriate and may not effectively manage EPS. Documenting the findings and continuing to monitor the client (Choice D) is important but not the priority when potential EPS is present; immediate action by notifying the healthcare provider is essential.
2. A client is diagnosed with schizophrenia and exhibits apathy, lack of energy, and lack of interest in daily activities. The nurse should recognize that these symptoms are most likely due to which of the following?
- A. Negative symptoms of schizophrenia.
- B. Positive symptoms of schizophrenia.
- C. Side effects of antipsychotic medication.
- D. Symptoms of depression.
Correct answer: A
Rationale: Apathy, lack of energy, and lack of interest in daily activities are negative symptoms of schizophrenia (A). Positive symptoms of schizophrenia include hallucinations and delusions (B). While antipsychotic medication side effects can sometimes cause lethargy or sedation (C), the scenario specifically describes negative symptoms. Depression can also cause similar symptoms (D), but in the context of schizophrenia, these are recognized as negative symptoms.
3. A client in the manic phase of bipolar disorder is pacing the hallway and talking rapidly. What is the best intervention for the nurse?
- A. Encourage the client to join a group activity.
- B. Offer the client a high-calorie snack and a drink.
- C. Direct the client to a quieter area of the unit.
- D. Instruct the client to sit down and relax.
Correct answer: B
Rationale: In the manic phase of bipolar disorder, clients often exhibit increased activity and may burn a lot of energy. Offering a high-calorie snack and a drink is the best intervention as it helps maintain their nutritional needs while allowing them to continue their activity. Encouraging the client to join a group activity (Choice A) may further stimulate their behavior. Directing the client to a quieter area (Choice C) might not address their energy expenditure. Instructing the client to sit down and relax (Choice D) may not be effective during the manic phase.
4. A client with post-traumatic stress disorder (PTSD) is experiencing a flashback. What is the nurse's priority action?
- A. Encourage the client to talk about the trauma.
- B. Help the client to focus on the present.
- C. Administer prescribed anti-anxiety medication.
- D. Leave the client alone to work through the flashback.
Correct answer: B
Rationale: The priority action is to help the client focus on the present (B), which can reduce the intensity of the flashback. Encouraging discussion of the trauma (A) should be done when the client is not actively experiencing a flashback. While medication (C) may be necessary, it is not the first priority in this situation. Leaving the client alone (D) is not appropriate as they need support to manage the flashback.
5. A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to a nurse, 'I'm finally cured.' The LPN/LVN interprets this behavior as a cue to modify the treatment plan by:
- A. Suggesting a reduction of medication
- B. Allowing increased 'in-room' activities
- C. Increasing the level of suicide precautions
- D. Allowing the client off-unit privileges as needed
Correct answer: C
Rationale: A sudden improvement in mood and declaring being cured can be warning signs of a decision to attempt suicide. Therefore, the appropriate action would be to increase the level of suicide precautions to ensure the safety of the client. This can involve closer monitoring and restriction of items that could be harmful. Choices A, B, and D are incorrect as they do not address the potential risk of suicide that may be present with the sudden change in behavior.
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