HESI LPN
HESI Mental Health Questions
Question 1 of 5
A male client with delirium becomes disoriented and confused in his room at night. The best initial nursing intervention is to:
Correct Answer: B
Rationale: The best initial nursing intervention for a male client with delirium who becomes disoriented and confused in his room at night is to use an indirect light source and turn off the television. This approach helps to reduce stimulation and confusion, aiding in the client's orientation and comfort. Moving the client next to the nurse's station (Choice A) may not address the root cause of disorientation and could disrupt the client's routine. Keeping the television and a soft light on (Choice C) may further contribute to the client's confusion. Playing soft music and maintaining a well-lit room (Choice D) may not be as effective in reducing stimulation and promoting orientation as using an indirect light source and turning off the television.
Question 2 of 5
A client's medication sheet contains a prescription for sertraline (Zoloft). To ensure safe administration of the medication, a nurse would administer the dose:
Correct Answer: B
Rationale: The correct answer is B: 'At the same time each evening.' Sertraline should be administered at the same time each evening to maintain steady drug levels and effectiveness. Choice A is incorrect because sertraline can be taken with or without food. Choice C is incorrect as sertraline does not need to be spaced around the clock. Choice D is incorrect as sertraline is a scheduled medication and should not be taken on an as-needed basis for complaints of depression.
Question 3 of 5
Which information should the LPN/LVN exclude in the nursing plan of care for a client with obsessive-compulsive disorder (OCD)?
Correct Answer: A
Rationale: The correct answer is A because including the medical diagnosis of the client in the nursing plan is redundant as the healthcare team is already aware of the diagnosis. The nursing plan of care for a client with OCD should focus on individualized goals, objectives, attendance at group therapy sessions, and self-care measures to improve hygiene. These components directly contribute to addressing the client's needs and promoting recovery. Therefore, the medical diagnosis does not need to be included in the nursing plan as it does not actively guide the day-to-day care and interventions for the client.
Question 4 of 5
A client is admitted to the mental health unit and reports taking extra anti-anxiety medication because, 'I'm so stressed out. I just wanted to go to sleep.' The nurse should plan one-on-one observation of the client based on which statement?
Correct Answer: D
Rationale: The correct answer is D because expressing feelings of hopelessness or nihilism can be indicators of a deeper, possibly dangerous level of depression. Choice A is incorrect as it indicates seeking help, Choice B suggests fatigue, and Choice C implies denial of needing help, none of which directly signify severe depression warranting one-on-one observation.
Question 5 of 5
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: The correct answer is option A: "Prolixin is the most effective with positive symptoms of schizophrenia." This answer is correct because fluphenazine (Prolixin) is a typical antipsychotic medication that primarily targets the positive symptoms of schizophrenia, such as hallucinations and delusions. It helps to reduce these symptoms and may not directly address negative symptoms like withdrawal and lack of motivation. Option B is incorrect because while Prolixin can help with positive symptoms, it may not necessarily address all negative symptoms immediately. Option C is incorrect as jumping to increase the dose without proper assessment or consultation may not be appropriate and could lead to adverse effects. Option D is incorrect because lack of motivation is not a common side effect of Prolixin, but rather a symptom of schizophrenia itself. In an educational context, it is important for mental health nursing students to understand the specific effects of different antipsychotic medications on different symptoms of schizophrenia. This knowledge helps in providing appropriate care and managing expectations for both clients and healthcare providers. Understanding the nuances of medication effects can improve patient outcomes and promote effective communication within the healthcare team.