HESI LPN
HESI Mental Health 2023 Questions
Question 1 of 5
A male client with borderline personality disorder is manipulative and consistently attempts to violate unit rules. What is the best approach for the nurse to take?
Correct Answer: A
Rationale: The correct approach for the nurse to take when dealing with a male client with borderline personality disorder who is manipulative and consistently attempts to violate unit rules is to enforce unit rules consistently with all clients. By maintaining consistency in enforcing rules, the nurse establishes clear boundaries and provides structure, which are essential for managing manipulative behavior in clients with borderline personality disorder. Ignoring the manipulative behaviors (
Choice
B) may lead to the reinforcement of negative behaviors. Providing the client with special privileges (
Choice
C) can enable further manipulation and is not recommended. Confronting the client directly about his behavior (
Choice
D) may escalate the situation and is less effective than consistent rule enforcement.
Question 2 of 5
A female client with depression attends a group and states that she sometimes misses her medication appointments because she feels very anxious about riding the bus. Which statement is the nurse's best response?
Correct Answer: D
Rationale: Encouraging the client to discuss coping mechanisms for anxiety is a supportive approach that empowers the client to manage their symptoms.
Choice A may not address the client's self-management and coping skills.
Choice B suggests using anxiety medication before riding the bus, which may not be the most appropriate solution.
Choice C acknowledges the anxiety but does not actively involve the client in finding solutions, unlike
Choice D which promotes client empowerment and self-efficacy.
Question 3 of 5
A young adult male with a history of substance abuse is admitted to the psychiatric unit for detoxification. He is agitated, sweating, and reports seeing bugs crawling on the walls. What is the priority nursing intervention?
Correct Answer: B
Rationale: The correct answer is to administer the prescribed benzodiazepine. This intervention helps manage the client's agitation and hallucinations, which are common symptoms during detoxification from substances. Reassuring the client that the bugs are not real (
Choice
A) may not be effective in addressing the underlying causes of the hallucinations. Placing the client in a quiet, dark room (
Choice
C) may help reduce sensory stimulation but does not directly address the client's symptoms. Encouraging the client to express his feelings (
Choice
D) is important for therapeutic communication but may not be the priority when the client is experiencing severe agitation and hallucinations.
Question 4 of 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.
Question 5 of 5
The nurse should hold the next scheduled dose of a client's haloperidol (Haldol) based on which assessment finding(s)?
Correct Answer: D
Rationale: A fever (
D) may indicate neuroleptic malignant syndrome (NMS), a potentially fatal complication of antipsychotics. The healthcare provider should be contacted before administering the next dose of Haldol. Dizziness when standing (
A), shuffling gait and hand tremors (
B), and urinary retention (
C) are all adverse effects of Haldol that, while concerning, do not pose immediate life-threatening risks compared to the potential severity of NMS indicated by a fever.