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 cli
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Nursing Elites

HESI LPN

HESI Mental Health Practice Exam

1. 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.

2. A client is responding to auditory hallucinations and shakes a fist at a nurse and says, 'Back off, witch!' The nurse follows the client into the day room. What action should the nurse implement?

Correct answer: C

Rationale: In situations where a client is responding to auditory hallucinations and displaying aggressive behavior, it is crucial for the nurse to ensure physical space between themselves and the client. This action can help de-escalate the situation and prevent any potential harm to both the nurse and the client. Sitting down near the client (Choice A) may escalate the situation by invading the client's personal space. Positioning oneself within an arm's length of the client (Choice B) may increase the risk of physical confrontation. Moving closer to the room's door (Choice D) may not be appropriate as it can block the client's exit route and escalate the situation further. Therefore, ensuring physical space between the nurse and the client (Choice C) is the most appropriate action to promote safety and prevent escalation.

3. A female client with major depression is prescribed fluoxetine (Prozac). She reports experiencing increased energy but still feels sad and hopeless. What is the nurse's best response?

Correct answer: B

Rationale: The correct answer is B. Increased energy without improvement in mood can increase the risk of self-harm in clients with depression. It is crucial for the nurse to recognize this potential risk and closely monitor the client for any signs of self-harm. Choice A is incorrect because dismissing the client's persistent feelings of sadness and hopelessness as normal may invalidate her experiences. Choice C is incorrect as fluoxetine (Prozac) typically starts showing effectiveness within a few weeks, so further delay is concerning. Choice D is incorrect because while discussing the client's feelings is important, the immediate focus should be on addressing the potential risk of self-harm associated with increased energy.

4. The LPN/LVN is caring for a client who has been prescribed a monoamine oxidase inhibitor (MAOI) for depression. Which statement by the client indicates a need for further teaching?

Correct answer: C

Rationale: The statement 'I can drink alcohol in moderation while taking this medication' indicates a need for further teaching because alcohol consumption can have dangerous interactions with MAOIs. MAOIs can interact with alcohol to cause a hypertensive crisis, which can be life-threatening. Choices A and B are correct statements as avoiding tyramine-rich foods and taking the medication with food can help prevent adverse effects. Choice D is incorrect because abruptly stopping an antidepressant medication like an MAOI can lead to withdrawal symptoms and a relapse of depression.

5. A female client with anorexia nervosa is admitted to the hospital. What is the priority assessment for the nurse to perform?

Correct answer: B

Rationale: The correct answer is to monitor the client's electrolyte levels. In clients with anorexia nervosa, electrolyte imbalances can lead to serious, potentially life-threatening complications such as cardiac arrhythmias. Assessing body image perception (choice A) is important but not the priority when compared to monitoring electrolyte levels. Evaluating exercise habits (choice C) and assessing the client's relationship with her family (choice D) are also important aspects of care but do not take precedence over monitoring electrolyte levels in a client with anorexia nervosa.

Similar Questions

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When a client with major depressive disorder expresses feelings of worthlessness and hopelessness, what is the nurse's priority intervention?
A client with bipolar disorder is prescribed lithium. What is the most important instruction the nurse should provide?
A 40-year-old male client diagnosed with schizophrenia and alcohol dependence has not had any visitors or phone calls since admission. He reports he has no family that cares about him and was living on the streets prior to this admission. According to Erikson's theory of psychosocial development, which stage is the client in at this time?
For a female client with major depressive disorder reporting feelings of hopelessness and helplessness, what is the nurse's priority intervention?

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