HESI LPN
HESI Mental Health 2023
1. A young adult male client, diagnosed with paranoid schizophrenia, believes that the world is trying to poison him. What intervention should the nurse include in this client's plan of care?
- A. Remind the client that his suspicions are not true.
- B. Ask one nurse to spend time with the client daily.
- C. Encourage the client to participate in group activities.
- D. Assign the client to a room closest to the activity room.
Correct answer: B
Rationale: A client with paranoid schizophrenia has difficulty with trust and developing a trusting relationship with one nurse (B) is likely to be therapeutic for this client. Choice (A) is argumentative and may increase the client's resistance. Choice (C) might be too overwhelming and anxiety-provoking for the client. Choice (D) could increase the client's stress and anxiety, which are counterproductive in managing paranoid ideations.
2. The nurse is caring for a client who received the first-time electroconvulsive therapy (ECT) a half hour ago. Which action should the nurse implement first?
- A. Offer oral fluids.
- B. Monitor vital signs.
- C. Evaluate ECT effectiveness.
- D. Encourage group participation.
Correct answer: B
Rationale: After a client receives electroconvulsive therapy (ECT), the nurse's priority should be to monitor vital signs. This is important to ensure the client's physical stability and detect any immediate complications post-procedure. Offering oral fluids, evaluating ECT effectiveness, and encouraging group participation are all important aspects of care but monitoring vital signs takes precedence in the immediate post-ECT period.
3. What intervention should the nurse implement during the administration of a vesicant chemotherapeutic agent via an IV site in the client's arm?
- A. Assess IV site frequently for signs of extravasation
- B. Monitor capillary refill distal to the infusion site
- C. Apply a topical anesthetic at the infusion site for burning
- D. Explain that temporary burning at the IV site may occur
Correct answer: A
Rationale: The correct intervention the nurse should implement during the administration of a vesicant chemotherapeutic agent via an IV site in the client's arm is to assess the IV site frequently for signs of extravasation. Vesicants are agents that can cause tissue damage if they leak into the surrounding tissues. Monitoring for signs of extravasation such as swelling, pain, or redness is crucial to prevent tissue damage and ensure prompt intervention if extravasation occurs. Choices B, C, and D are incorrect because monitoring capillary refill, applying a topical anesthetic for burning, and explaining temporary burning do not directly address the risk of extravasation associated with vesicant chemotherapeutic agents.
4. Which of the following manifestations confirms the presence of pediculosis capitis in students?
- A. Scratching the head more than usual
- B. Flakes evident on a student's shoulders
- C. Oval pattern occipital hair loss
- D. Whitish oval specks sticking to the hair
Correct answer: D
Rationale: The correct answer is D. Whitish oval specks sticking to the hair shaft are nits, which are a definitive sign of pediculosis capitis (head lice). A: Scratching the head more than usual is a common symptom but not confirmatory of head lice infestation. B: Flakes evident on a student's shoulders may indicate dandruff or dry scalp, not necessarily head lice. C: Oval pattern occipital hair loss is not a typical manifestation of pediculosis capitis.
5. A client with a history of hypertension is prescribed a diuretic. Which of the following laboratory values should the nurse monitor to evaluate the effectiveness of the medication?
- A. Monitor serum calcium levels.
- B. Monitor serum potassium levels.
- C. Monitor serum sodium levels.
- D. Monitor serum magnesium levels.
Correct answer: B
Rationale: The correct answer is to monitor serum potassium levels. When a client is prescribed a diuretic, monitoring serum potassium levels is essential to evaluate the medication's effectiveness and to detect potential electrolyte imbalances. Diuretics can cause potassium loss, leading to hypokalemia, which can have serious consequences such as cardiac arrhythmias. Monitoring serum calcium levels (Choice A) is not typically required when assessing the effectiveness of diuretics. Similarly, monitoring serum sodium levels (Choice C) is important for other conditions but is not the primary concern when evaluating diuretic therapy. Monitoring serum magnesium levels (Choice D) is also important, but potassium levels are more critical in assessing diuretic effectiveness and preventing complications.