the lpnlvn is caring for a client who is experiencing alcohol withdrawal which intervention should the nurse implement first
Logo

Nursing Elites

HESI LPN

HESI Mental Health 2023

1. The LPN/LVN is caring for a client who is experiencing alcohol withdrawal. Which intervention should the nurse implement first?

Correct answer: B

Rationale: When caring for a client experiencing alcohol withdrawal, the first intervention the nurse should implement is to monitor the client's vital signs. Vital sign monitoring is crucial to assess for any potential complications such as hypertension, tachycardia, fever, or other signs of autonomic hyperactivity. Administering medication like lorazepam (Ativan) would come after assessing the vital signs to determine the need for pharmacological intervention. Placing the client on seizure precautions is important, but assessing vital signs takes precedence to ensure immediate safety. Encouraging the client to express feelings about withdrawal is a supportive intervention but does not address the immediate physiological risk associated with alcohol withdrawal.

2. A client with major depressive disorder is prescribed an SSRI. After one week, the client reports feeling no improvement in mood. What is the best response by the RN?

Correct answer: A

Rationale: The correct response is A: 'It is common for antidepressants to take several weeks to have an effect.' This response is appropriate because SSRI and other antidepressants often require several weeks to exhibit improvement in mood. It is crucial to educate the client about this delay to manage expectations and promote adherence to the medication regimen. Choice B is incorrect as switching medications prematurely is not typically recommended after just one week. Choice C is incorrect because it sets unrealistic expectations for immediate improvement. Choice D is incorrect as it may come across as accusatory and should not be the initial response.

3. A client with generalized anxiety disorder is being taught about buspirone (BuSpar) by a nurse. Which statement by the client indicates a need for further teaching?

Correct answer: D

Rationale: The statement 'I can drink alcohol while taking this medication' (D) indicates a need for further teaching. Clients should avoid alcohol while taking buspirone because it can increase the risk of side effects such as dizziness and drowsiness. Choices A, B, and C are correct statements regarding buspirone and do not require further teaching.

4. A client diagnosed with paranoid schizophrenia is still withdrawn, unkempt, and unmotivated to get out of bed. A mental health aide asks the nurse why the client is this way after being on fluphenazine (Prolix) 10 mg for 7 days. The LPN/LVN should tell the health aide:

Correct answer: A

Rationale: Prolixin is more effective with positive symptoms of schizophrenia, such as hallucinations and delusions, rather than negative symptoms like withdrawal and lack of motivation.

5. What is the most therapeutic nursing response for a client with borderline personality disorder who engages in self-mutilating behavior?

Correct answer: B

Rationale: The most therapeutic nursing response for a client with borderline personality disorder engaging in self-mutilating behavior is to discuss what the client was feeling before self-harming. This approach helps in exploring the underlying triggers and emotions that lead to self-harm. Option A is directive and may come across as judgmental rather than empathetic. Option C can lead to feelings of betrayal and breach of trust. Option D is a closed-ended question that may not facilitate open communication or exploration of emotions.

Similar Questions

What are neurotransmitters?
A female client with schizophrenia tells the nurse that she believes her brain is controlled by the CIA. The nurse recognizes this as which type of delusion?
Which action should the nurse implement during the termination phase of the nurse-client relationship?
A client with generalized anxiety disorder (GAD) is prescribed buspirone (BuSpar). The client asks how long it will take for the medication to start working. What is the nurse's best response?
The nurse is conducting discharge teaching for a client with schizophrenia who plans to live in a group home. Which statement is most indicative of the need for careful follow-up after discharge?

Access More Features

HESI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses