a client with obsessive compulsive disorder ocd spends hours each day washing their hands which nursing intervention is most appropriate initially
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HESI Mental Health Practice Exam

1. A client with obsessive-compulsive disorder (OCD) spends hours each day washing their hands. Which nursing intervention is most appropriate initially?

Correct answer: A

Rationale: Initially, it is most appropriate to allow the client to continue the behavior to reduce anxiety (A). For clients with OCD, abruptly stopping compulsive behaviors can lead to increased anxiety and distress. Setting strict limits (B) may exacerbate anxiety at first. Distraction with other activities (C) may not address the underlying issue effectively. While support groups (D) can be beneficial, they are typically introduced after establishing trust and gradually working on reducing compulsive behaviors.

2. A client with bipolar disorder is started on a regimen of valproic acid (Depakote). Which laboratory test is most important for the nurse to monitor?

Correct answer: A

Rationale: The correct answer is A: Liver function tests. Valproic acid can cause hepatotoxicity, leading to liver damage. Monitoring liver function tests is crucial to detect any early signs of liver impairment. Kidney function tests (Choice B) are not the most important to monitor in this case. Blood glucose levels (Choice C) and serum sodium levels (Choice D) are not directly affected by valproic acid and are not the priority for monitoring in a client taking this medication.

3. A client with schizophrenia is experiencing auditory hallucinations. What is the most appropriate nursing intervention?

Correct answer: A

Rationale: The most appropriate nursing intervention for a client with schizophrenia experiencing auditory hallucinations is to encourage the client to focus on reality-based activities. This intervention helps redirect their attention away from hallucinations, promoting engagement with the environment. Choice B is incorrect as telling the client that the voices are not real may invalidate their experiences and worsen the therapeutic relationship. Choice C may increase the client's distress by focusing on the hallucinations. Choice D might not be helpful as interacting with others who are not experiencing hallucinations may not address the client's current needs.

4. What is the most therapeutic nursing response for a client with borderline personality disorder who engages in self-mutilating behavior?

Correct answer: B

Rationale: The most therapeutic nursing response for a client with borderline personality disorder engaging in self-mutilating behavior is to discuss what the client was feeling before self-harming. This approach helps in exploring the underlying triggers and emotions that lead to self-harm. Option A is directive and may come across as judgmental rather than empathetic. Option C can lead to feelings of betrayal and breach of trust. Option D is a closed-ended question that may not facilitate open communication or exploration of emotions.

5. Which diet selection by a client who is depressed and taking the MAO inhibitor tranylcypromine sulfate (Parnate) indicates to the nurse that the client understands the dietary restrictions imposed by this medication regimen?

Correct answer: D

Rationale: Roast beef, baked potato with butter, and iced tea are safe choices as they do not contain tyramine, which must be avoided with MAO inhibitors like Parnate. Tyramine-rich foods like aged cheeses, certain meats, and fermented products can cause a hypertensive crisis when combined with MAO inhibitors. Choices A, B, and C contain foods high in tyramine and are not recommended for individuals taking MAO inhibitors.

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