the nurse asks a female client with a borderline personality disorder how do you feel about your children not coming to visit this weekend the client
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Nursing Elites

HESI LPN

Mental Health HESI 2023

1. The nurse asks a female client with borderline personality disorder, 'How do you feel about your children not coming to visit this weekend?' The client looks out the window and replies, 'I really don't care.' Which response is best for the nurse to provide?

Correct answer: A

Rationale: Acknowledging the client's non-verbal behavior, such as looking out the window, demonstrates active listening and provides the client with an opportunity to explore their feelings further. Choice B is incorrect as it accuses the client of lying without any evidence, which can damage the therapeutic relationship. Choice C is inappropriate as it dismisses the client's feelings and suggests a group discussion without addressing the client's emotions directly. Choice D is also incorrect as it focuses on the children's actions rather than the client's feelings, missing an opportunity for therapeutic communication.

2. A client who is being treated with lithium carbonate for bipolar disorder develops diarrhea, vomiting, and drowsiness. What action should the LPN/LVN take?

Correct answer: B

Rationale: When a client being treated with lithium carbonate for bipolar disorder develops symptoms like diarrhea, vomiting, and drowsiness, it could indicate lithium toxicity. The appropriate action for the LPN/LVN is to notify the healthcare provider immediately of these symptoms before the next administration of the drug. This prompt communication is crucial to ensure that the healthcare provider can assess the situation, adjust the treatment plan if necessary, and prevent potential complications associated with lithium toxicity. Option A is incorrect because administering an antidote should be based on the healthcare provider's assessment. Option C is incorrect as these symptoms are not normal side effects and could indicate a serious issue. Option D is incorrect because refusing to administer the drug without consulting the healthcare provider could delay necessary interventions.

3. 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?

Correct answer: C

Rationale: The correct answer is C. The statement 'Only my belief in God can help me' suggests a reliance on spiritual intervention over medical treatment, raising concerns about potential non-compliance. This indicates the need for close follow-up to ensure the client's well-being and adherence to the prescribed treatment plan. Choices A, B, and D do not directly address potential issues related to treatment compliance or the need for follow-up care after discharge.

4. What assessment is the priority focus for a client with major depression?

Correct answer: B

Rationale: The correct answer is B: Suicidal ideation. When dealing with a client diagnosed with major depression, assessing for suicidal ideation is of utmost importance. Individuals with major depression have an increased risk of suicide; hence, evaluating their risk for self-harm is crucial. Mood and affect, while important, come secondary to ensuring the safety of the client. Nutritional status and fluid and electrolyte balance are essential components of care but are not the priority when dealing with a client with major depression.

5. A client with generalized anxiety disorder (GAD) is prescribed buspirone (BuSpar). The nurse should include which information in the client's discharge teaching?

Correct answer: B

Rationale: Corrected Rationale: Buspirone takes time to become fully effective, so the client should be informed to expect a gradual improvement in anxiety symptoms. Choice A is incorrect because buspirone is not associated with physical dependence. Choice C is not directly related to buspirone but is generally a good practice when taking any medication. Choice D is less common with buspirone compared to other anxiety medications.

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