HESI LPN
HESI Mental Health
1. The LPN/LVN is caring for a client who has recently been diagnosed with bipolar disorder. The client asks, 'Why do I have to take medication every day?' What is the best response by the nurse?
- A. The medication will help stabilize your mood and prevent mood swings.
- B. You will need to take this medication for the rest of your life.
- C. The medication will help you feel better and more in control of your emotions.
- D. The medication is needed to control your symptoms and help you function better.
Correct answer: A
Rationale: The best response by the nurse is to explain that the medication will help stabilize the client's mood and prevent mood swings. This response provides the client with a clear understanding of how the medication works in managing bipolar disorder. Choice B is not the best response as it may cause unnecessary worry about lifelong medication dependence. Choice C is not as specific in addressing the purpose of the medication for bipolar disorder. Choice D is not as focused on the effect of the medication on mood stabilization, which is crucial in managing bipolar disorder.
2. A male client with schizophrenia tells the nurse that the FBI is monitoring his phone calls. What is the nurse's best response?
- A. Let's talk about your feelings of being monitored.
- B. There is no evidence that the FBI is monitoring your calls.
- C. Why do you think the FBI is interested in your phone calls?
- D. I can assure you that your phone calls are not being monitored.
Correct answer: A
Rationale: The correct response is to choose A: 'Let's talk about your feelings of being monitored.' This response shows empathy and encourages the client to express his feelings. Engaging the client in a discussion about his feelings can help address underlying fears without directly challenging the delusion. Choice B is incorrect because directly denying the delusion may lead to increased distrust or agitation in the client. Choice C may come across as confrontational, which can exacerbate the client's paranoia. Choice D offers a false sense of assurance and does not address the client's concerns effectively.
3. Which action should the nurse implement first for a client experiencing alcohol withdrawal?
- A. Apply vest or extremity restraints.
- B. Give an alpha-adrenergic blocker.
- C. Provide a diet high in protein and calories.
- D. Prepare the environment to prevent self-injury.
Correct answer: D
Rationale: The correct action for the nurse to implement first for a client experiencing alcohol withdrawal is to prepare the environment to prevent self-injury. Clients undergoing alcohol withdrawal are at risk of seizures and other symptoms that may lead to self-harm. By ensuring a safe environment, the nurse can mitigate the risk of injury. Applying restraints (Choice A) should only be considered if less restrictive measures fail, as restraints can agitate the client further. Giving an alpha-adrenergic blocker (Choice B) may be part of the treatment plan for alcohol withdrawal but is not the first action to take. Providing a diet high in protein and calories (Choice C) is important for overall health but is not the priority when addressing immediate safety concerns.
4. A RN is preparing the physical environment to interview a new client for admission to the mental health unit. Which environmental setting facilitates the best outcome of the interview?
- A. Dim the lights in the room to help the patient feel calm.
- B. Sit within two feet of the client to enhance the level of safety and security.
- C. Reduce the noise level in the room by turning off the television and radio.
- D. Position a table between the client and the RN for extra personal space.
Correct answer: C
Rationale: Reducing the noise level in the room by turning off the television and radio is the best choice among the options provided. This setting helps create a calm and focused environment, which facilitates better communication and assessment during the interview. Dimming the lights might not be suitable for all clients and could potentially hinder communication. Sitting too close or placing a table between the client and the RN may affect the client's comfort level and openness during the interview.
5. A male client who has been on lithium therapy for 5 years is experiencing frequent urination and increased thirst. What should the nurse's next action be?
- A. Instruct the client to increase fluid intake.
- B. Assess for signs of lithium toxicity.
- C. Suggest the client reduce salt intake.
- D. Notify the healthcare provider immediately.
Correct answer: B
Rationale: Frequent urination and increased thirst can be signs of lithium toxicity, which can lead to serious complications if not addressed promptly. Assessing for signs of lithium toxicity is crucial to determine the client's condition and prevent further harm. Instructing the client to increase fluid intake (Choice A) may worsen the situation by exacerbating lithium toxicity. Suggesting the client reduce salt intake (Choice C) is not the priority when signs of toxicity are present. Notifying the healthcare provider immediately (Choice D) is important, but the initial action should be to assess the client for signs of lithium toxicity to provide immediate care.
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