HESI LPN
Mental Health HESI 2023
1. A client with bipolar disorder is being treated with lithium. The nurse should monitor the client for which early sign of lithium toxicity?
- A. Diarrhea
- B. Tremors
- C. Polyuria
- D. Blurred vision
Correct answer: A
Rationale: Corrected Rationale: Diarrhea is an early sign of lithium toxicity. When a client being treated with lithium presents with diarrhea, it can indicate the beginning of lithium toxicity. Monitoring for this symptom is crucial as it can progress to more severe toxicity if not addressed promptly. Tremors (choice B) are more commonly associated with the therapeutic effects of lithium rather than toxicity. Polyuria (choice C) is a common side effect of lithium, but it is not typically an early sign of toxicity. Blurred vision (choice D) is not a common early sign of lithium toxicity. Therefore, option A is the correct answer.
2. A nurse is caring for a client with depression who is prescribed fluoxetine (Prozac). The client reports difficulty sleeping. What is the most appropriate nursing intervention?
- A. Encourage the client to take short naps during the day.
- B. Suggest the client drink a warm beverage before bedtime.
- C. Recommend the client exercise immediately before bedtime.
- D. Advise the client to take a sleep aid nightly.
Correct answer: B
Rationale: The most appropriate nursing intervention for a client with difficulty sleeping due to depression and prescribed fluoxetine is to suggest the client drink a warm beverage before bedtime. This intervention can promote relaxation and help establish a bedtime routine, potentially improving sleep quality. Encouraging short naps during the day (Choice A) may disrupt the client's nighttime sleep schedule. Recommending exercise immediately before bedtime (Choice C) can have a stimulating effect, making it harder for the client to fall asleep. Advising the client to take a sleep aid nightly (Choice D) should only be done under the guidance of a healthcare provider due to potential interactions with fluoxetine.
3. A nurse working on a mental health unit receives a community call from a person who is tearful and states, 'I just feel so nervous all of the time. I don't know what to do about my problems. I haven't been able to sleep at night and have hardly eaten for the past 3 or 4 days.' The nurse should initiate a referral based on which assessment?
- A. Altered thought processes.
- B. Moderate levels of anxiety.
- C. Inadequate social support.
- D. Altered health maintenance.
Correct answer: B
Rationale: The nurse should initiate a referral based on moderate levels of anxiety (B) as the client reports feeling nervous all the time, sleep disturbances, poor appetite, and difficulty solving problems. These symptoms are indicative of significant anxiety levels. The client does not mention symptoms related to altered thought processes (A) or inadequate social support (C). There is insufficient information to suggest altered health maintenance (D) as a reason for referral in this scenario.
4. The LPN/LVN is caring for a client with depression who has been prescribed an SSRI. The client reports feeling more energy but is still feeling hopeless. What should the nurse be most concerned about?
- A. That the client may act on suicidal thoughts.
- B. That the client may engage in impulsive behavior.
- C. That the client may be experiencing the side effects of the medication.
- D. That the client may be at risk for developing serotonin syndrome.
Correct answer: A
Rationale: The nurse should be most concerned that the client may act on suicidal thoughts. An increase in energy combined with persistent feelings of hopelessness can indicate a higher risk of suicide. While impulsive behavior can be a concern, the primary worry should be the client's safety regarding suicidal ideation. Side effects of the medication are important to monitor but do not take precedence over the risk of self-harm. Serotonin syndrome is a potential concern with SSRIs, but in this scenario, the client's mental health and safety are the immediate priority.
5. In the described scenario, a manic client threatens a nurse with physical violence after being told they cannot have a stripper perform. What is the most appropriate action for the LPN/LVN to take?
- A. Orient the client to time, person, and place
- B. Tell the client that the behavior is inappropriate
- C. Escort the manic client to her room, with assistance
- D. Tell the client that smoking privileges are revoked for 24 hours
Correct answer: C
Rationale: In this situation, where the manic client becomes verbally abusive and threatens physical violence, the most appropriate action for the LPN/LVN is to escort the client to her room with assistance. This action helps ensure the safety of both the client and the nurse, while also providing a controlled environment that can help de-escalate the situation. Choices A and B do not address the immediate safety concerns presented by the client's behavior. Choice D, revoking smoking privileges, is not directly related to the client's current behavior and does not address the threat of violence.
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