a nurse is caring for a client with depression who has been prescribed sertraline zoloft the client reports experiencing nausea what is the nurses bes
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Nursing Elites

HESI LPN

HESI Mental Health 2023

1. A nurse is caring for a client with depression who has been prescribed sertraline (Zoloft). The client reports experiencing nausea. What is the nurse's best response?

Correct answer: B

Rationale: The correct answer is B: "Nausea is a common side effect of sertraline, and clients should be reassured that it usually decreases as their body adjusts to the medication." Choice A is incorrect because abruptly stopping the medication without consulting a healthcare provider can be harmful. Choice C is a good suggestion to reduce nausea by taking the medication with food but does not address the temporary nature of the side effect. Choice D is unnecessary at this point since nausea is a common side effect that may improve with time.

2. 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.

3. A client in the mental health unit believes that the food is being poisoned. What intervention(s) would be helpful when attempting to encourage the client to eat? Select one that does not apply.

Correct answer: B

Rationale: Using open-ended questions and focusing on the client's self-disclosure about food preferences can help build rapport and trust with the client, encouraging them to eat. Identifying the reasons the client has for not wanting to eat can provide insights into their concerns. However, offering opinions about the necessity for adequate nutrition may come across as imposing views on the client, potentially leading to resistance. This approach may not be as effective in encouraging the client to eat as it could create a power dynamic that hinders the therapeutic relationship.

4. A client with a diagnosis of schizophrenia is experiencing auditory hallucinations. What is the most appropriate nursing intervention?

Correct answer: C

Rationale: The most appropriate nursing intervention for a client with schizophrenia experiencing auditory hallucinations is to encourage them to engage in reality-based activities. This intervention helps manage auditory hallucinations by redirecting the client's focus away from the hallucinations. Choice A is not recommended as it may exacerbate the hallucinations or distress the client. Choice B is incorrect because denying the reality of the voices can invalidate the client's experiences. Choice D, asking the client to focus on positive thoughts, may not be effective in addressing the auditory hallucinations directly.

5. An LPN/LVN is conducting an initial assessment on a client in crisis. When assessing the client's perception of the precipitating event that led to the crisis, the appropriate question to ask is:

Correct answer: C

Rationale: The correct question to ask when assessing a client's perception of the precipitating event that led to a crisis is 'What leads you to seek help now?' This question directly addresses the client's current situation and triggers that brought them to seek assistance. Choices A and B are more focused on the client's social support system rather than the root cause of the crisis. Choice D addresses coping mechanisms rather than the actual trigger for seeking help.

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