a nurse is planning care for a client with anorexia nervosa which goal should be prioritized
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Nursing Elites

HESI LPN

Mental Health HESI Practice Questions

1. When planning care for a client with anorexia nervosa, which goal should be prioritized?

Correct answer: D

Rationale: The correct answer is D because achieving normal electrolyte balance is critical in clients with anorexia nervosa. Electrolyte imbalances can lead to serious, life-threatening complications such as cardiac arrhythmias and organ failure. While establishing normal eating patterns (choice A) and verbalizing feelings about food and weight (choice B) are important aspects of treatment, addressing electrolyte balance takes precedence due to the immediate risks associated with imbalances. Additionally, setting a weight gain goal of 2 pounds per week (choice C) may not be appropriate initially as rapid refeeding can also lead to electrolyte imbalances and other complications.

2. A 30-year-old sales manager tells the nurse, 'I am thinking about a job change. I don't feel like I am living up to my potential.' Which of Maslow's developmental stages is the sales manager attempting to achieve?

Correct answer: A

Rationale: The correct answer is 'Self-Actualization.' Self-actualization is the highest level of Maslow's hierarchy of needs, focusing on fulfilling one's full potential and achieving personal growth. In this scenario, the sales manager expressing a desire for a job change because they don't feel they are living up to their potential aligns with the characteristics of self-actualization. Choices B, C, and D represent lower levels of Maslow's hierarchy: 'Loving and Belonging' pertains to social needs, 'Basic Needs' encompass physiological and safety needs, and 'Safety and Security' are fundamental needs related to protection and stability.

3. A male employee who is assessed weekly in the employee clinic for blood pressure because of a history of hypertension tells the nurse that he is so upset with one of his co-workers that he would like to shoot him. What action should the nurse take first?

Correct answer: A

Rationale: Determining if the client has access to a weapon is critical for immediate safety and to prevent potential harm.

4. A client with generalized anxiety disorder is being treated with lorazepam (Ativan). What is the most important teaching point for the LPN/LVN to reinforce?

Correct answer: B

Rationale: The most important teaching point for the LPN/LVN to reinforce is to avoid drinking alcohol while taking lorazepam (Ativan). Alcohol can enhance the sedative effects of lorazepam, increasing the risk of severe side effects and complications. Choice A is incorrect because lorazepam can be taken with or without food. Choice C is not the most critical teaching point, although it is essential to avoid activities that require mental alertness until the effects of the medication are known. Choice D is incorrect because abruptly stopping lorazepam can lead to withdrawal symptoms and should only be done under medical supervision.

5. A male client with delirium becomes disoriented and confused in his room at night. The best initial nursing intervention is to:

Correct answer: B

Rationale: The best initial nursing intervention for a male client with delirium who becomes disoriented and confused in his room at night is to use an indirect light source and turn off the television. This approach helps to reduce stimulation and confusion, aiding in the client's orientation and comfort. Moving the client next to the nurse's station (Choice A) may not address the root cause of disorientation and could disrupt the client's routine. Keeping the television and a soft light on (Choice C) may further contribute to the client's confusion. Playing soft music and maintaining a well-lit room (Choice D) may not be as effective in reducing stimulation and promoting orientation as using an indirect light source and turning off the television.

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