a young adult female client is admitted to a psychiatric facility with a medical diagnosis of bulimia nervosa which nursing intervention has the highe
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Nursing Elites

HESI LPN

HESI Mental Health Practice Exam

1. A young adult female client is admitted to a psychiatric facility with a medical diagnosis of bulimia nervosa. Which nursing intervention has the highest priority?

Correct answer: D

Rationale: The correct answer is D. Assessing and reporting the client's electrolyte status to the healthcare provider is the highest priority in a client with bulimia nervosa. Electrolyte imbalances, such as hypokalemia and metabolic alkalosis, are common due to purging behaviors associated with bulimia. Monitoring electrolyte levels is crucial to prevent life-threatening complications. Choices A, B, and C are incorrect because while therapy and monitoring for binging activities are important, addressing the electrolyte imbalances caused by purging behaviors takes precedence in the immediate care of a client with bulimia nervosa.

2. During the manic phase of bipolar disorder, what is the priority nursing intervention for a female client who has not slept for the past 48 hours, is hyperactive, talkative, and engaging in risky behaviors?

Correct answer: B

Rationale: The correct priority nursing intervention for a female client in the manic phase of bipolar disorder, who has not slept for 48 hours, is hyperactive, talkative, and engaging in risky behaviors, is to provide a safe environment and limit stimuli. This approach is crucial to prevent harm to the client and others. Encouraging a quiet activity (Choice A) may not effectively address the need for safety during the manic phase. Administering a sedative (Choice C) should be done under the guidance of a healthcare provider and does not address the immediate safety concerns. Discussing consequences of risky behaviors (Choice D) may not be effective during the manic phase when the client's judgment is impaired.

3. A client with obsessive-compulsive disorder (OCD) repeatedly checks the locks on the doors. What is the best nursing intervention?

Correct answer: A

Rationale: The best nursing intervention when dealing with a client with OCD who repeatedly checks locks is to encourage the client to discuss their fears. This approach can help the client identify underlying anxiety triggers and work towards developing alternative coping mechanisms. Choice B, limiting the client's time for ritualistic behavior, may increase anxiety and worsen symptoms by creating a sense of urgency. Choice C, assisting the client to complete the ritual faster, does not address the underlying issues and may reinforce the behavior. Choice D, preventing the client from engaging in the behavior, can lead to increased anxiety and distress for the client.

4. During initial assessment of the teenager, what information is most important for the nurse to obtain from the parents?

Correct answer: C

Rationale: The correct answer is C. It's crucial to determine if the teenager might have taken other substances besides the pain pills mentioned by the mother. This information is vital for effective treatment because knowing the full scope of substances involved helps in managing potential interactions, side effects, and the overall condition of the patient. Options A, B, and D are not as critical in the immediate assessment compared to knowing if the teenager has ingested any other drugs.

5. A male client with alcohol use disorder is admitted for detoxification. The nurse knows that which symptom is a sign of severe alcohol withdrawal?

Correct answer: B

Rationale: Seizures are a sign of severe alcohol withdrawal and can be life-threatening, requiring immediate medical attention. Bradycardia, hyperglycemia, and constipation are not typically associated with severe alcohol withdrawal. Bradycardia is more commonly seen in opioid withdrawal, hyperglycemia could be due to other reasons like uncontrolled diabetes, and constipation is not a typical symptom of severe alcohol withdrawal.

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