HESI LPN
HESI Mental Health Practice Exam
1. What is the best initial action for the nurse to take with a manic depressive male client who becomes loud and verbally aggressive towards a nurse?
- A. Have the staff escort the client to his room.
- B. Tell the client that his behavior will be recorded in his record.
- C. Redirect the client by asking him to engage in a game with peers.
- D. Review the medication record for an antipsychotic drug.
Correct answer: C
Rationale: In dealing with a manic depressive client who is being verbally aggressive, the best initial action for the nurse is to redirect the client by engaging him in a more constructive activity, such as playing card games with peers. This approach can help de-escalate the situation, shift the client's focus positively, and provide a distraction from the current behavior. Having the staff escort the client to his room may escalate the situation further. Threatening to record the behavior in his record is not likely to be effective in managing the immediate situation. Reviewing the medication record for an antipsychotic drug is important but would not be the best initial action in this scenario when the client is being verbally aggressive.
2. The community health nurse talks to a male client who has bipolar disorder. The client explains that he sleeps 4 to 5 hours a night and is working with his partner to start two new businesses and build an empire. The client stopped taking his medications several days ago. What nursing problem has the highest priority?
- A. Excessive work activity.
- B. Decreased need for sleep.
- C. Medication management.
- D. Inflated self-esteem.
Correct answer: D
Rationale: The priority is to manage the client's medication adherence to prevent escalation of manic behavior. Inflated self-esteem is the highest priority as it indicates the client's potential for harmful behaviors due to lack of medication compliance. While excessive work activity and decreased need for sleep are characteristics of mania, they are not as immediately concerning as the risk of harm related to inflated self-esteem.
3. A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to a nurse, 'I'm finally cured.' The LPN/LVN interprets this behavior as a cue to modify the treatment plan by:
- A. Suggesting a reduction of medication
- B. Allowing increased 'in-room' activities
- C. Increasing the level of suicide precautions
- D. Allowing the client off-unit privileges as needed
Correct answer: C
Rationale: A sudden improvement in mood and declaring being cured can be warning signs of a decision to attempt suicide. Therefore, the appropriate action would be to increase the level of suicide precautions to ensure the safety of the client. This can involve closer monitoring and restriction of items that could be harmful. Choices A, B, and D are incorrect as they do not address the potential risk of suicide that may be present with the sudden change in behavior.
4. A client with post-traumatic stress disorder (PTSD) is experiencing a flashback. What is the nurse's priority action?
- A. Encourage the client to talk about the trauma.
- B. Help the client to focus on the present.
- C. Administer prescribed anti-anxiety medication.
- D. Leave the client alone to work through the flashback.
Correct answer: B
Rationale: The priority action is to help the client focus on the present (B), which can reduce the intensity of the flashback. Encouraging discussion of the trauma (A) should be done when the client is not actively experiencing a flashback. While medication (C) may be necessary, it is not the first priority in this situation. Leaving the client alone (D) is not appropriate as they need support to manage the flashback.
5. A female client with borderline personality disorder expresses fear of being abandoned by the nursing staff. What is the best nursing intervention?
- A. Reassure the client that she will not be abandoned.
- B. Set limits on the client's behavior and enforce them consistently.
- C. Encourage the client to talk about her fears.
- D. Rotate the nursing staff assigned to the client frequently.
Correct answer: B
Rationale: The best nursing intervention for a client with borderline personality disorder expressing fear of abandonment is to set limits on the client's behavior and enforce them consistently. This approach helps establish boundaries and provides a sense of security for the client. Choice A may provide temporary reassurance but does not address the core issue or help the client develop coping strategies. Choice C is important but should be accompanied by setting limits to address the underlying fear of abandonment. Choice D of rotating staff frequently can exacerbate the client's fear of abandonment by reinforcing the idea of being left.
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