a female client with bipolar disorder is in the manic phase and has not slept for the past 48 hours she is hyperactive talkative and engaging in risky
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HESI Mental Health Practice Exam

1. During the manic phase of bipolar disorder, what is the priority nursing intervention for a female client who has not slept for the past 48 hours, is hyperactive, talkative, and engaging in risky behaviors?

Correct answer: B

Rationale: The correct priority nursing intervention for a female client in the manic phase of bipolar disorder, who has not slept for 48 hours, is hyperactive, talkative, and engaging in risky behaviors, is to provide a safe environment and limit stimuli. This approach is crucial to prevent harm to the client and others. Encouraging a quiet activity (Choice A) may not effectively address the need for safety during the manic phase. Administering a sedative (Choice C) should be done under the guidance of a healthcare provider and does not address the immediate safety concerns. Discussing consequences of risky behaviors (Choice D) may not be effective during the manic phase when the client's judgment is impaired.

2. A client with post-traumatic stress disorder (PTSD) reports having frequent nightmares. What is the nurse's best response?

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.

3. An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days. Which assessment finding requires immediate follow-up?

Correct answer: A

Rationale: The correct answer is A. Expressing that life is without purpose can indicate deepening depression or suicidal ideation, which requires immediate attention. While sweating, fatigue, drowsiness, nausea, and loss of appetite can be side effects of duloxetine (Cymbalta), they do not indicate the same level of urgency as a statement suggesting deepening depression or suicidal ideation.

4. A client with bipolar disorder is prescribed lithium. What is the most important instruction the nurse should provide?

Correct answer: C

Rationale: Maintaining a consistent sodium intake is crucial for clients taking lithium because changes in sodium levels can impact lithium concentrations, potentially leading to toxicity. It is essential to avoid excessive sodium intake, as both low and high levels can affect lithium levels. Choices A, B, and D are incorrect. A high potassium diet is not a concern with lithium therapy. While taking lithium with food can help reduce gastrointestinal side effects, it is not the most important instruction. Finally, abruptly stopping lithium can lead to a recurrence of symptoms or a worsening of the condition, so it is vital to follow the prescribed regimen.

5. A male client with borderline personality disorder is manipulative and consistently attempts to violate unit rules. What is the best approach for the nurse to take?

Correct answer: A

Rationale: The correct approach for the nurse to take when dealing with a male client with borderline personality disorder who is manipulative and consistently attempts to violate unit rules is to enforce unit rules consistently with all clients. By maintaining consistency in enforcing rules, the nurse establishes clear boundaries and provides structure, which are essential for managing manipulative behavior in clients with borderline personality disorder. Ignoring the manipulative behaviors (Choice B) may lead to the reinforcement of negative behaviors. Providing the client with special privileges (Choice C) can enable further manipulation and is not recommended. Confronting the client directly about his behavior (Choice D) may escalate the situation and is less effective than consistent rule enforcement.

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