a client is admitted to the mental health unit and reports taking extra anti anxiety medication because im so stressed out i just wanted to go to slee
Logo

Nursing Elites

HESI LPN

HESI Mental Health

1. A client is admitted to the mental health unit and reports taking extra anti-anxiety medication because, 'I'm so stressed out. I just wanted to go to sleep.' The nurse should plan one-on-one observation of the client based on which statement?

Correct answer: D

Rationale: The correct answer is D because expressing feelings of hopelessness or nihilism can be indicators of a deeper, possibly dangerous level of depression. Choice A is incorrect as it indicates seeking help, Choice B suggests fatigue, and Choice C implies denial of needing help, none of which directly signify severe depression warranting one-on-one observation.

2. A nurse is caring for a client who is experiencing severe anxiety. Which intervention is most appropriate for the nurse to implement?

Correct answer: A

Rationale: The correct intervention for a client experiencing severe anxiety is to instruct the client to take deep breaths and focus on the present. Deep breathing can help reduce the physiological symptoms of anxiety and provide the client with a way to regain control over their emotions. Choice B is incorrect as discussing fears in detail may escalate anxiety levels. Choice C is inappropriate as distracting the client may not address the root cause of anxiety. Choice D is not recommended as leaving the client alone can increase feelings of isolation and distress.

3. A client who has just been sexually assaulted is calm and quiet. The nurse analyzes this behavior as indicating which defense mechanism?

Correct answer: A

Rationale: The correct answer is A: Denial. In this situation, the client's calm and quiet demeanor after a traumatic event like sexual assault may indicate denial, a defense mechanism where the individual refuses to acknowledge the reality of the distressing event. Choice B, Projection, involves attributing one's thoughts or feelings to others. Choice C, Rationalization, is a defense mechanism where logical reasoning is used to justify behaviors or feelings. Choice D, Intellectualization, is a defense mechanism where excessive reasoning or logic is used to avoid uncomfortable emotions.

4. A nurse is caring for a client with major depressive disorder who is withdrawn and refuses to participate in group activities. What is the best nursing intervention?

Correct answer: A

Rationale: Encouraging the client to attend at least one group session is the best nursing intervention in this scenario. By gently encouraging participation, the nurse can help the client start to engage with others, which may gradually improve their mood and social interaction. Choice B, respecting the client's wish to remain isolated, may further exacerbate the client's withdrawal and depression by reinforcing avoidance behavior. Choice C, arranging for individual therapy sessions, can be beneficial but may not address the specific need for social interaction. Choice D, offering a list of activities to choose from, does not directly address the client's difficulty in participating in group activities and may not provide the necessary support in overcoming social withdrawal.

5. A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. What action should the nurse implement?

Correct answer: A

Rationale: When a client is guarded, suspicious, and resistant to talking, it is important for the nurse to attempt to ask the client simple questions. Simple questions can help build rapport, establish trust, and create a non-threatening environment. This approach may ease the client into more detailed discussions while reducing feelings of suspicion. Postponing the interview may increase the client's anxiety and distrust, while asking another nurse to talk with the client may disrupt continuity of care and the establishment of a therapeutic relationship. Documenting the client's behavior is important for the client's medical record, but it should not be the first action taken in this situation.

Similar Questions

A homeless person who is in the manic phase of bipolar disorder is admitted to the mental health unit. Which laboratory finding obtained on admission is most important for the nurse to report to the healthcare provider?
During the manic phase of bipolar disorder, what is the priority nursing intervention for a female client who has not slept for the past 48 hours, is hyperactive, talkative, and engaging in risky behaviors?
A nurse determines that the wife of an alcoholic client is benefitting from attending an Al-Anon group when the nurse hears the wife say:
A male client who is participating in an anger management assignment asks if he can make a leather belt in occupational therapy. The client begins pounding the leather vigorously with a mallet to imprint designs on the belt. What defense mechanism is the client using?
A 35-year-old male client on the psychiatric unit of a general hospital believes that someone is trying to poison him. The nurse understands that a client's delusions are most likely related to his

Access More Features

HESI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses