a client with schizophrenia is admitted to the psychiatric care unit for aggressive behavior auditory hallucinations and potential for self harm the c
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Nursing Elites

HESI LPN

HESI Mental Health 2023

1. A client with schizophrenia is admitted to the psychiatric care unit for aggressive behavior, auditory hallucinations, and potential for self-harm. The client has not been taking medications as prescribed and insists that the food has been poisoned and refuses to eat. What intervention should the RN implement?

Correct answer: D

Rationale: The correct intervention is to provide the client with food in unopened containers. This approach can help alleviate the client's fear of poisoning and encourage eating. Choice A may not address the client's specific fear and may be perceived as dismissive. Choice B, while providing information about symptoms of schizophrenia, does not address the immediate issue of the client's refusal to eat due to the fear of poisoning. Choice C of obtaining an order for tube feeding is premature and invasive before exploring less restrictive options.

2. The occupational health nurse is working with a female employee who was just notified that her child was involved in a MVA and taken to the hospital. The employee states, 'I can't believe this. What should I do?' Which response is best for the nurse to provide in this crisis?

Correct answer: D

Rationale: Providing immediate practical support, such as arranging transportation to the hospital, is the best response in this crisis situation. It helps the employee to take immediate action and supports her in a highly stressful moment. Choice A focuses on the employee's thoughts rather than providing immediate aid. Choice B is not a priority as the severity can be addressed later. Choice C puts the decision-making burden on the employee at a time of distress, which is not ideal. Therefore, choice D is the most appropriate response in this situation.

3. A client is admitted with a diagnosis of depression. The nurse knows that which characteristic is most indicative of depression?

Correct answer: D

Rationale: A negative view of self and the future (D) is a prominent characteristic of depression. It reflects the core symptoms of low self-esteem and hopelessness that are commonly associated with this condition. Grandiose ideation (A) and suspiciousness of others (C) are more indicative of other mental health disorders like paranoia. While self-destructive thoughts (B) can be present in depression, they are not as specific and common as the negative self-view and hopelessness, making option (D) the most indicative characteristic of depression.

4. A client who has recently been diagnosed with schizophrenia tells the LPN/LVN, 'I hear voices telling me to hurt myself.' What is the most appropriate nursing action?

Correct answer: D

Rationale: The correct answer is to refer the client for a psychiatric evaluation. The client's statement indicating hearing voices telling them to hurt themselves is a serious concern and suggests a risk for self-harm. Referring the client for a psychiatric evaluation is crucial for further assessment and intervention by mental health professionals. Choice A is incorrect because ignoring the voices may not address the client's safety. Choice B is incorrect as it oversimplifies the situation and does not address the immediate risk. Choice C is not as comprehensive as referring for a psychiatric evaluation, which is necessary in this situation.

5. A 72-year-old female client is admitted to the psychiatric unit with a diagnosis of major depression. Which statement by the client should be of greatest concern to the nurse and require further assessment?

Correct answer: A

Rationale: Sometimes a client will use an analogy to describe themselves, and (A) would be an indication for conducting a suicide assessment. (B) could have a variety of etiologies, and while further assessment is indicated, this statement does not indicate potential suicide. The normal grief process differs from depression, and at this client's age, peer/cohort deaths are more frequent, so (C) would be within normal limits. (D) is an expression of low self-esteem typical of depression. Choices (B), (C), and (D) are examples of decreased energy and mood levels which would negate suicide ideation at this time.

Similar Questions

The nurse is performing intake interviews at a psychiatric clinic. A female client with a known history of drug abuse reports that she had a heart attack four years ago. Use of which substance abuse places the client at the highest risk for myocardial infarction?
A male client approaches the nurse with an angry expression on his face and raises his voice, saying, 'My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out!' The nurse recognizes that the client is using which defense mechanism?
A client is diagnosed with schizophrenia and exhibits apathy, lack of energy, and lack of interest in daily activities. The nurse should recognize that these symptoms are most likely due to which of the following?
The wife of a male client recently diagnosed with schizophrenia asks the nurse, 'What exactly is schizophrenia? Is my husband all right?' Which response is best for the LPN/LVN to provide to this family member?
A 45-year-old female client is admitted to the psychiatric unit for evaluation. Her husband states that she has been reluctant to leave home for the last six months. The client has not gone to work for a month and has been terminated from her job. She has not left the house since that time. This client is displaying symptoms of which disorder?

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