a nurse is caring for a client with obsessive compulsive disorder ocd who spends hours checking and rechecking the locks on the doors what is the best
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HESI Mental Health Practice Exam

1. A client with obsessive-compulsive disorder (OCD) spends hours checking and rechecking the locks on the doors. What is the best nursing intervention?

Correct answer: B

Rationale: The best nursing intervention for a client with OCD who spends excessive time checking locks is to encourage the client to discuss the thoughts and feelings behind the behavior. By exploring the underlying anxiety and triggers, the client can gain insight and work towards behavior modification. Choice A is incorrect because enabling the behavior does not address the underlying issues. Choice C is incorrect as it may lead to increased anxiety and distress. Choice D is incorrect as it does not address the root cause of the behavior.

2. A client with alcohol use disorder is admitted for detoxification. The nurse should monitor for which early sign of alcohol withdrawal?

Correct answer: C

Rationale: Tremors are an early sign of alcohol withdrawal. They are caused by hyperactivity of the autonomic nervous system and are a common symptom during the early stages of withdrawal. Monitoring tremors is crucial as they can progress to more severe symptoms if not managed effectively. Seizures (Choice A) typically occur later in the withdrawal process and are a more severe symptom. Visual hallucinations (Choice B) usually manifest after tremors and are considered a mid-stage symptom. Delirium tremens (Choice D) is a severe form of alcohol withdrawal that typically occurs 2-3 days after the last drink, characterized by confusion, disorientation, and severe autonomic hyperactivity.

3. An elderly client was prescribed Ativan 1 mg three times a day to help calm her anxiety after her husband's death. The next day the client calls her daughter asking when she is picking her up to go to the graveside. The client says she has been walking up and down the driveway for the past hour waiting for her daughter. Noting the client's agitation, hyperactivity, and insistence, the daughter calls the nurse to report her mother's behavior. What should the nurse suspect?

Correct answer: C

Rationale: A paradoxical reaction to Ativan, where the drug causes opposite effects such as increased agitation and hyperactivity, should prompt immediate cessation of the medication. In this scenario, the client was prescribed Ativan to help calm her anxiety, but instead, she is displaying symptoms of increased agitation and hyperactivity, indicating a paradoxical reaction. Choice A is incorrect because the symptoms described do not align with mania. Choice B is incorrect as there is no mention of a medication interaction. Choice D is incorrect as the symptoms are more indicative of a paradoxical reaction rather than overwhelming grief.

4. The LPN/LVN is caring for a client who was recently diagnosed with a mental illness. The client asks, 'Will I be able to live a normal life?' What is the best response for the nurse to provide?

Correct answer: C

Rationale: The best response for the nurse is to provide the client with hope while acknowledging the importance of their treatment and choices. Choice C addresses the client's concern by highlighting the impact of their treatment and personal choices on their future. It encourages personal responsibility and active participation in their recovery. Choices A and B may sound reassuring, but they do not empower the client to take an active role in their well-being. Choice D, while promoting individuality, does not directly address the client's question about living a normal life after a mental illness diagnosis.

5. A male client with mental illness and substance dependency tells the mental health nurse that he has started using illegal drugs again and wants to seek treatment. Since he has a dual diagnosis, which person is best for the nurse to refer this client to first?

Correct answer: B

Rationale: The case manager (B) is responsible for coordinating community services, making them the best person to refer the client to first as they can describe available treatment options. The emergency room nurse (A) is unnecessary unless the client's behaviors pose imminent threats. The clinic healthcare provider (C) and support group sponsor (D) may be useful but coordinating a treatment program tailored to the client's needs is the priority in this scenario.

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