HESI Mental Health 2023

Question 1 of 5

Which statement best demonstrates the nurse's role in ensuring that each client's rights are respected?

A. Autonomy is a fundamental right for each client. B. Client rights are guaranteed by both state and federal laws. C. Being respectful and concerned will ensure attentiveness to clients' rights. D. Regardless of the client's condition, nurses must respect client rights.

Correct Answer: C

Rationale: The statement 'Being respectful and concerned will ensure attentiveness to clients' rights' best demonstrates the nurse's role in ensuring that each client's rights are respected. This choice emphasizes the importance of being attentive and considerate towards clients to uphold their rights.
Choice A is too general and lacks the direct connection to the nurse's role.
Choice B highlights the legal aspect but does not specifically address the nurse's role.
Choice D, although true, is not as comprehensive as choice C in describing the nurse's active role in respecting client rights.

Question 2 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?

A. Reassure the client that the bugs are not real. B. Administer the prescribed benzodiazepine. C. Place the client in a quiet, dark room. D. Encourage the client to express his feelings.

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 3 of 5

The nurse plans to help an 18-year-old female intellectually disabled client ambulate on the first postoperative day after an appendectomy. When the nurse tells the client it is time to get out of bed, the client becomes angry and tells the nurse, 'Get out of here! I'll get up when I'm ready!' Which response is best for the nurse to make?

A. Your healthcare provider has prescribed ambulation on the first postoperative day. B. You must ambulate to avoid complications that could cause more discomfort than ambulating. C. I know how you feel. You're angry about having to ambulate, but this will help you get well. D. I'll be back in 30 minutes to help you get out of bed and walk around the room.

Correct Answer: D

Rationale: (
D) provides a 'cooling off' period, is firm, direct, non-threatening, and avoids arguing with the client. (
A) is avoiding responsibility by referring to the healthcare provider. (
B) is trying to reason with an intellectually disabled client and is threatening the client with 'complications.' (
C) is telling the client how she feels (angry), and the nurse does not really 'know' how this client feels, unless the nurse is also intellectually disabled and has also just had an appendectomy.

Question 4 of 5

A 38-year-old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her, she refuses to eat and tells the nurse, 'I know you are trying to poison me with that food.' Which response would be most appropriate for the nurse to make?

A. 'I'll leave your tray here. I am available if you need anything else.' B. 'You're not being poisoned. Why do you think someone is trying to poison you?' C. 'No one on this unit has ever died from poisoning. You're safe here.' D. 'I will talk to your healthcare provider about the possibility of changing your diet.'

Correct Answer: A

Rationale:
Choice (
A) offers support without confrontation, allowing the client to feel safe and respected.

Choices (
B) and (
C) directly challenge the client's delusion, which can increase anxiety and distrust.
Choice (
D) focuses on a non-essential issue and does not address the client's immediate emotional needs.

Question 5 of 5

A client is admitted to the hospital with a diagnosis of anorexia nervosa. What is the most important intervention for the LPN/LVN to implement during the first 24 hours of hospitalization?

A. Encourage the client to eat small, frequent meals. B. Monitor the client's vital signs and weight. C. Establish a trusting relationship with the client. D. Provide emotional support to the client.

Correct Answer: B

Rationale: The correct answer is to monitor the client's vital signs and weight. This intervention is crucial in assessing the severity of the client's condition and planning appropriate care. Vital signs and weight monitoring help in evaluating the client's physiological status and identifying any immediate concerns related to anorexia nervosa.

Choices A, C, and D are important aspects of care for a client with anorexia nervosa; however, during the initial 24 hours of hospitalization, monitoring vital signs and weight takes precedence as it provides essential data for the client's ongoing management and treatment.

Nurselytic

HESI LPN

HESI LPN