an adolescent who attempted suicide with a drug overdose arrives in the emergency department with an empty 30 tablet bottle of acetaminophen tylenol w
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Nursing Elites

HESI LPN

HESI Mental Health Practice Exam

1. An adolescent who attempted suicide with a drug overdose arrives in the emergency department with an empty 30-tablet bottle of acetaminophen (Tylenol). Which action should the nurse implement?

Correct answer: A

Rationale: The correct action for the nurse to implement is to administer acetylcysteine (Mucomyst). Acetylcysteine is the antidote for acetaminophen overdose and should be administered promptly to prevent liver damage. Monitoring cardiac rhythm for flat T waves (Choice B) is not specific to acetaminophen overdose and is more related to cardiac conditions. Checking serum AST and ALT levels (Choice C) may be done later but is not the initial priority in this situation. Similarly, preparing to administer Syrup of Ipecac (Choice D) is not recommended anymore in cases of overdose as it can cause more harm.

2. A young adult male client is admitted to the psychiatric unit because of a recent suicide attempt. His wife filed for divorce six months ago, he lost his job three months ago, and his best friend moved to another city two weeks ago. Which intervention should the nurse include in the client's plan of care?

Correct answer: D

Rationale: Encouraging activities that allow the client to exert control over his environment can be therapeutic in cases of depression and stress. It helps improve the client's sense of agency, which is essential for promoting feelings of empowerment and self-worth. Choice A could potentially be overwhelming for the client, especially considering his recent suicide attempt and ongoing stressors. Choice B might not be the most beneficial intervention as isolation could further exacerbate feelings of loneliness and hopelessness. Choice C, avoiding discussing upsetting subjects, may prevent the client from addressing and processing his emotions, hindering therapeutic progress.

3. An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days. Which assessment finding requires immediate follow-up?

Correct answer: A

Rationale: The correct answer is A. Expressing that life is without purpose can indicate deepening depression or suicidal ideation, which requires immediate attention. While sweating, fatigue, drowsiness, nausea, and loss of appetite can be side effects of duloxetine (Cymbalta), they do not indicate the same level of urgency as a statement suggesting deepening depression or suicidal ideation.

4. A nurse is providing discharge teaching to a client with major depressive disorder who is prescribed fluoxetine (Prozac). What is the most important teaching point for the nurse to include?

Correct answer: B

Rationale: The correct answer is B because SSRIs like fluoxetine typically take several weeks to reach their full therapeutic effect, so it's important to set realistic expectations for the client. Choice A is incorrect as dizziness is a common side effect but not the most important teaching point. Choice C is incorrect as avoiding tyramine-rich foods is more relevant for MAOIs. Choice D is incorrect as fluoxetine should be taken consistently, not only when the client feels depressed, to maintain therapeutic blood levels.

5. A female victim of sexual assault is being seen in the crisis center. The client states that she still feels 'as though the rape just happened yesterday,' even though it has been a few months since the incident. The appropriate nursing response is which of the following?

Correct answer: C

Rationale: The correct response is to encourage the client to talk about the event that makes them feel as though the rape just occurred. This approach can help the client process their feelings and experiences, which is crucial in dealing with trauma. Choice A is dismissive and negates the client's feelings, which can be harmful. Choice B, although acknowledging the time needed to heal, does not actively address the client's current feelings. Choice D shifts the focus to future fears rather than addressing the client's current emotional state.

Similar Questions

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A nurse is caring for a client with depression who is prescribed fluoxetine (Prozac). The client reports difficulty sleeping. What is the most appropriate nursing intervention?
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