a female victim of sexual assault is being seen in the crisis center the client states that she still feels as though the rape just happened yesterday
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Nursing Elites

HESI LPN

HESI Mental Health 2023

1. A female victim of sexual assault is being seen in the crisis center. The client states that she still feels 'as though the rape just happened yesterday,' even though it has been a few months since the incident. The appropriate nursing response is which of the following?

Correct answer: C

Rationale: The correct response is to encourage the client to talk about the event that makes them feel as though the rape just occurred. This approach can help the client process their feelings and experiences, which is crucial in dealing with trauma. Choice A is dismissive and negates the client's feelings, which can be harmful. Choice B, although acknowledging the time needed to heal, does not actively address the client's current feelings. Choice D shifts the focus to future fears rather than addressing the client's current emotional state.

2. A client's medication sheet contains a prescription for sertraline (Zoloft). To ensure safe administration of the medication, a nurse would administer the dose:

Correct answer: B

Rationale: The correct answer is B: 'At the same time each evening.' Sertraline should be administered at the same time each evening to maintain steady drug levels and effectiveness. Choice A is incorrect because sertraline can be taken with or without food. Choice C is incorrect as sertraline does not need to be spaced around the clock. Choice D is incorrect as sertraline is a scheduled medication and should not be taken on an as-needed basis for complaints of depression.

3. A female client with severe depression who has been on antidepressants for two weeks suddenly becomes more energetic and talkative. What action should the RN take first?

Correct answer: B

Rationale: A sudden increase in energy and talkativeness in a client with severe depression who has been on antidepressants for a short period may indicate an increased risk of suicide due to the potential shift from profound sadness to motivation to act. The first action the RN should take is to monitor the client closely for signs of suicidal behavior. Encouraging participation in group activities or praising the client for the apparent improvement may overlook the potential risk of suicidal behavior. While discussing the client's progress with the healthcare provider is important, the immediate concern is to ensure the client's safety by closely monitoring for any signs of suicidal ideation or behavior.

4. A client is being successfully treated with clozapine (Clozaril). Which of the following statements by the client reflects a need for further teaching about managing the drug's adverse effects?

Correct answer: A

Rationale: Choice A reflects a need for further teaching as the client mistakenly believes that eating too many fruits causes constipation, showing a misunderstanding about dietary fiber's role in preventing constipation. Choices B, C, and D demonstrate accurate understanding of managing clozapine's adverse effects, such as taking it with food to avoid nausea, getting up slowly to prevent dizziness, and pushing oneself when feeling sleepy.

5. A client with major depressive disorder is prescribed a selective serotonin reuptake inhibitor (SSRI). Which side effect should the nurse educate the client about?

Correct answer: B

Rationale: The correct answer is B: Sexual dysfunction. Sexual dysfunction is a common side effect of SSRIs. While hypertension (A) can occur with other medications, it is not typically associated with SSRIs. Increased appetite (C) and weight gain (D) are potential side effects of some antidepressants, but sexual dysfunction is more specific to SSRIs. Therefore, the nurse should educate the client about the risk of sexual dysfunction when taking an SSRI.

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