an lpnlvn is reviewing the assessment data of a client admitted to the mental health unit the nurse notes that the admission nurse documented that the
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HESI Mental Health

1. An LPN/LVN is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse determines that this type of crisis is caused by:

Correct answer: B

Rationale: The correct answer is B: 'The death of a loved one.' A situational crisis, like the death of a loved one, can lead to anxiety due to a significant change or loss in the person's life. Choices A, C, and D involve traumatic events, but a situational crisis typically refers to life events that disrupt an individual's normal pattern of living, such as the death of a loved one.

2. During a mental status exam, what factor should the nurse remember when assessing a client's intelligence?

Correct answer: B

Rationale: The correct answer is B. Intelligence is indeed influenced by social and cultural beliefs. It is essential to recognize that intelligence is not solely determined by innate abilities but can also be shaped by various external factors such as cultural background, education, and social environment. Choices A, C, and D are incorrect because acute psychiatric illnesses do not necessarily impair intelligence, poor concentration skills do not always suggest limited intelligence, and the inability to think abstractly alone does not always indicate limited intelligence.

3. A male hospital employee is pushed out of the way by a female employee because of an oncoming gurney. The pushed employee becomes very angry and swings at the female employee. Both employees are referred for counseling with the staff psychiatric nurse. Which factor in the pushed employee's history is most related to the reaction that occurred?

Correct answer: C

Rationale: The correct answer is C: 'Was physically abused by his mother.' A history of physical abuse can lead to heightened responses to physical contact. In this scenario, the employee's reaction of becoming very angry and swinging at the female employee after being pushed may be influenced by past experiences of physical abuse. This history can contribute to increased sensitivity to physical interactions and may trigger defensive or aggressive responses. Choices A, B, and D are less directly related to the employee's reaction in this specific context. While worrying about losing his job to a woman could contribute to underlying stress or insecurity, torturing animals as a child reflects a different type of behavioral issue, and hating to be touched by anyone suggests personal boundaries unrelated to the observed behavior in this scenario.

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 nurse is providing discharge teaching to a client with schizophrenia who is prescribed clozapine (Clozaril). Which information should the nurse include?

Correct answer: A

Rationale: The correct answer is A: 'You need to come in for regular blood tests.' Clozapine can cause agranulocytosis, a potentially life-threatening condition, so regular blood tests are required to monitor the client's white blood cell count. Choice B is incorrect because clozapine is associated with weight gain, not weight loss. Choice C is incorrect because the client should never stop taking clozapine abruptly due to the risk of withdrawal symptoms and symptom relapse. Choice D is incorrect because avoiding foods high in tyramine is typically associated with MAOIs, not clozapine.

Similar Questions

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Select the nursing interventions for a hospitalized client with mania who is exhibiting manipulative behavior. Select one intervention that does not apply.
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?
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