HESI RN
Quizlet Mental Health HESI
1. What should the nurse initially assess when a high school girl reveals engaging in self-induced vomiting as a weight-control measure?
- A. National percentile of weight and height.
- B. Frequency of bingeing and purging behaviors.
- C. Perceptions of family and social relationships.
- D. School grades and extracurricular activities.
Correct answer: B
Rationale: The correct answer is assessing the frequency of bingeing and purging behaviors. This assessment is crucial in understanding the severity of the eating disorder and developing an appropriate treatment plan. Options A, C, and D are not the initial priority when dealing with a student engaging in harmful behaviors related to eating disorders. While weight and height, family relationships, and academic performance are important aspects to consider, the immediate focus should be on evaluating the behaviors directly linked to the reported issue.
2. A client who recently experienced the death of a significant other arrives at the mental health center. The client reports loss of interest in usual activities, expresses a wish to be with the deceased significant other, has been eating very little, and has not slept in several days. Which client statement is most important for the RN to explore at this time?
- A. Not sleeping for several days.
- B. Wishing to be with the deceased significant other.
- C. Lack of interest in usual activities.
- D. Eating very little.
Correct answer: A
Rationale: The most important client statement for the RN to explore in this scenario is the client not sleeping for several days. The lack of sleep is a critical indicator of possible severe depression or suicidal ideation that requires immediate attention. While expressing a wish to be with the deceased significant other, having a lack of interest in usual activities, and eating very little are concerning, the immediate focus should be on the client's severe sleep disturbance as it can pose an immediate risk to their well-being and safety.
3. A male client with bipolar disorder who began taking lithium carbonate five days ago is complaining of excessive thirst, and the RN finds him attempting to drink water from the bathroom sink faucet. Which intervention should the RN implement?
- A. Report the client’s serum lithium level to the healthcare provider (HCP).
- B. Encourage the client to suck on hard candy to relieve the symptoms.
- C. No action is needed since polydipsia is a common side effect.
- D. Tell the client that drinking from the faucet is not allowed.
Correct answer: B
Rationale: Encouraging the client to suck on hard candy is the appropriate intervention in this situation. Excessive thirst is a common side effect of lithium therapy. Sucking on hard candy can help alleviate the symptom without posing any harm. Reporting the client's serum lithium level to the healthcare provider (Choice A) is not necessary at this point as the symptom of excessive thirst is a known side effect and does not indicate toxicity. No action is needed (Choice C) is incorrect because addressing the client's distress is essential. Telling the client that drinking from the faucet is not allowed (Choice D) does not address the underlying issue of excessive thirst and may cause further distress to the client.
4. An older male client with schizophrenia is found smearing feces on the bathroom walls of the chronic mental health unit where he resides. What action should the RN implement?
- A. Explain that the feces belong in the toilet.
- B. Show the client how to clean the walls.
- C. Escort the client out of the bathroom.
- D. Assist the client to clean the walls.
Correct answer: C
Rationale: Escorting the client out of the bathroom is the most appropriate action to take in this situation. This helps prevent further inappropriate behavior and maintains hygiene, while avoiding reinforcement of the behavior. Option A, explaining that the feces belong in the toilet, may not be effective as the behavior is likely a manifestation of the client's condition rather than a lack of understanding. Option B, showing the client how to clean the walls, may not address the underlying issue and could potentially reinforce the behavior. Option D, assisting the client to clean the walls, may also reinforce the behavior and is not the best approach to managing the situation.
5. The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. What information should the nurse explore in-depth with the client based on this screening tool?
- A. Consumption, liver enzymes, gastrointestinal complaints, and bleeding.
- B. Minimizing drinking, frequently missing family events, guilt about drinking, and amount of daily intake.
- C. Cancer screening results, anger, gastritis, daily alcohol intake.
- D. Efforts to cut down, annoyance with questions, guilt, drinking as an “Eye-opener.â€
Correct answer: D
Rationale: The correct answer is D. The CAGE questionnaire is a screening tool for alcohol use disorder. Each letter in CAGE represents a key question: Cutting down, Annoyance by criticisms, Guilty feelings, and Eye-openers. These questions help assess problematic drinking behaviors and can provide valuable insights into the client's alcohol consumption habits. Choices A, B, and C do not directly align with the specific areas of inquiry covered by the CAGE questionnaire, making them incorrect. Therefore, the nurse should focus on exploring the client's efforts to cut down, annoyance with questions, feelings of guilt, and the use of alcohol as an “Eye-opener†based on this screening tool.
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