a client with schizophrenia is being discharged on antipsychotic medication what is the most important instruction the nurse should provide
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Nursing Elites

HESI LPN

Mental Health HESI 2023

1. When a client with schizophrenia is being discharged on antipsychotic medication, what is the most important instruction the nurse should provide?

Correct answer: C

Rationale: The correct answer is to instruct the client to report any unusual muscle movements immediately. These movements may indicate extrapyramidal symptoms (EPS) or tardive dyskinesia, which are serious side effects of antipsychotic medications that require immediate attention. Choice A is incorrect because stopping the medication without medical advice can lead to a relapse of symptoms. Choice B is important but not as critical as monitoring for EPS. Choice D is incorrect because driving readiness is not directly related to antipsychotic medication instructions.

2. 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?

Correct answer: A

Rationale: The correct answer is A: Decreased thyroid stimulating hormone level. Hyperthyroidism causes an increased level of serum thyroid hormones (T3 and T4), which inhibit the release of TSH. In this case, a decreased TSH level can indicate hyperthyroidism, which can present with manic behavior. Elevated liver function profile (B) is not directly related to the manic phase of bipolar disorder. Increased white blood cell count (C) typically indicates an infection or inflammation, not directly related to the manic phase. Decreased hematocrit and hemoglobin levels (D) may suggest anemia but are not as crucial in the context of a manic phase of bipolar disorder.

3. An adult female client tells the nurse that though she is afraid her abusive boyfriend might one day kill her, she keeps hoping that he will change. What action should the nurse take first?

Correct answer: B

Rationale: Exploring the client's readiness to discuss the situation is the correct first step. It allows the nurse to assess the client's emotional state, willingness to seek help, and readiness to address the abusive relationship. This approach helps build trust and rapport with the client, paving the way for further interventions. Discussing treatment options for abusive partners (Choice A) may be premature and not well-received if the client is not ready to address the situation. Determining the frequency and type of abuse (Choice C) is important but not the immediate priority compared to assessing the client's readiness to talk. Reporting the finding to the police (Choice D) should be done if there is an immediate threat to the client's safety, but exploring the client's readiness to discuss the situation should be the initial step to provide support and intervention.

4. A client with bipolar disorder is being discharged with a prescription for lithium. What is the most important instruction the nurse should provide?

Correct answer: B

Rationale: The correct answer is to instruct the client to drink plenty of fluids, especially during hot weather. Maintaining adequate hydration is crucial for clients taking lithium as dehydration can lead to lithium toxicity. Choice A is incorrect because while it is important to monitor sodium intake, staying hydrated is more critical. Choice C is incorrect as lithium is usually recommended to be taken with food to reduce stomach upset. Choice D is also important but not the most crucial instruction compared to ensuring proper hydration.

5. The LPN/LVN is caring for a client with post-traumatic stress disorder (PTSD). Which intervention is most appropriate for the nurse to implement?

Correct answer: B

Rationale: Assisting the client in developing coping strategies is an appropriate intervention for managing PTSD. This approach helps the client build resilience and learn how to effectively cope with symptoms. Choice A, encouraging the client to talk about the traumatic event, may not be appropriate as it can potentially re-traumatize the client. Referring the client to a PTSD support group, as in choice C, can be beneficial but may not be the most immediate intervention. Administering medications, as in choice D, is important in some cases, but focusing on coping strategies should be prioritized as a holistic approach to managing PTSD.

Similar Questions

A client with schizophrenia is being treated with risperidone (Risperdal). The nurse notices that the client has a shuffling gait and tremors. What is the nurse's priority action?
A female client with post-traumatic stress disorder (PTSD) has been experiencing flashbacks. Which intervention should the nurse implement to help the client?
A client on the psychiatric unit appears to imitate a certain nurse on the unit. The client seeks out this particular nurse and imitates her mannerisms. Which defense mechanism does the nurse recognize in this client?
A client with an eating disorder is planning to attend group meetings with Overeaters Anonymous. The LPN/LVN describes this group to the client, knowing that which finding(s) are characteristic of this form of self-help group? Select one that does not apply.
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