HESI LPN
HESI Mental Health 2023
1. A client with obsessive-compulsive disorder (OCD) repeatedly washes her hands throughout the day. What is the most therapeutic nursing intervention?
- A. Allow the client to continue the behavior to reduce anxiety.
- B. Encourage the client to talk about the underlying fears.
- C. Restrict the client's access to soap and water.
- D. Schedule a time for the client to perform the ritual.
Correct answer: B
Rationale: Encouraging the client to talk about the underlying fears is the most therapeutic nursing intervention for a client with OCD who repeatedly washes her hands. By discussing the fears, the client can gain insight into the behavior and work towards reducing the compulsion. Choice A is incorrect as allowing the client to continue the behavior can perpetuate the OCD symptoms. Choice C is incorrect as restricting access to soap and water can lead to increased anxiety and distress. Choice D is incorrect as scheduling a time for the client to perform the ritual does not address the underlying fears driving the behavior.
2. A client with generalized anxiety disorder is being treated with lorazepam (Ativan). What is the most important teaching point for the LPN/LVN to reinforce?
- A. Take the medication on an empty stomach.
- B. Avoid drinking alcohol while taking this medication.
- C. This medication may cause drowsiness, so avoid driving.
- D. You can stop taking the medication once you feel better.
Correct answer: B
Rationale: The most important teaching point for the LPN/LVN to reinforce is to avoid drinking alcohol while taking lorazepam (Ativan). Alcohol can enhance the sedative effects of lorazepam, increasing the risk of severe side effects and complications. Choice A is incorrect because lorazepam can be taken with or without food. Choice C is not the most critical teaching point, although it is essential to avoid activities that require mental alertness until the effects of the medication are known. Choice D is incorrect because abruptly stopping lorazepam can lead to withdrawal symptoms and should only be done under medical supervision.
3. A client with post-traumatic stress disorder (PTSD) reports having frequent nightmares. What is the nurse's best response?
- A. Nightmares are common with PTSD and should decrease over time.
- B. Try to avoid thinking about the trauma before going to bed.
- C. Let's discuss some relaxation techniques you can use before bedtime.
- D. I will ask the healthcare provider to prescribe a sleep aid.
Correct answer: C
Rationale: The best response for the nurse is to discuss relaxation techniques with the client that can help reduce anxiety and stress before bedtime. This approach may potentially decrease the frequency of nightmares by promoting a more calming and peaceful pre-sleep routine. Choice A is incorrect because while nightmares can be common with PTSD, it is not guaranteed that they will decrease over time. Choice B is incorrect as avoiding thinking about the trauma may not address the underlying issue causing the nightmares. Choice D is incorrect as prescribing a sleep aid should be considered as a last resort after trying non-pharmacological interventions.
4. An 86-year-old female client with Alzheimer's disease is wandering the busy halls of the extended care facility and asks the nurse, "Where should I stand for the parade?" Which response is best for the LPN/LVN to provide?
- A. Anywhere you want to stand as long as you do not get hurt by those in the parade.
- B. You are confused because of all the activity in the hall. There is no parade.
- C. Let us go back to the activity room and see what is going on in there.
- D. Remember I told you that this is a nursing home and I am your nurse.
Correct answer: C
Rationale: Redirecting the client to a less confusing environment can help reduce anxiety and reorient her to reality.
5. A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone (Risperdal). When the client walks to the nurse's station in a laterally contracted position, he states that something has made his body contort into a monster. What action should the nurse take?
- A. Medicate the client with the prescribed antipsychotic thioridazine (Mellaril).
- B. Offer the client a prescribed physical therapy hot pack for muscle spasms.
- C. Direct the client to occupational therapy to distract him from somatic complaints.
- D. Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia.
Correct answer: D
Rationale: The correct action for the nurse to take in this situation is to administer the prescribed anticholinergic benztropine (Cogentin) for dystonia. Dystonia can be a side effect of antipsychotic medications like risperidone, leading to involuntary muscle contractions and abnormal postures. Benztropine is an anticholinergic medication commonly used to treat dystonia. Choices A, B, and C are incorrect because thioridazine is not the appropriate medication in this case, a hot pack would not address the underlying issue of dystonia, and occupational therapy is not the primary intervention for addressing acute dystonic reactions.
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