HESI LPN
HESI Mental Health 2023
1. 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.
2. What action should the nurse take after a client produces the first of a series of sputum samples for cytology?
- A. Ensure the client remains NPO until all samples are collected
- B. Transport the sputum container to the laboratory in a biohazard bag
- C. Discard the initial sample and document the time it was obtained
- D. Document the time the client last ate or drank on the laboratory slip
Correct answer: B
Rationale: The correct action for the nurse to take after a client produces the first of a series of sputum samples for cytology is to transport the sputum container to the laboratory in a biohazard bag. This is important to ensure proper handling and prevent contamination of the sample. Choice A is incorrect because there is no need to keep the client NPO until all samples are collected. Choice C is incorrect as the initial sample should not be discarded but rather transported to the laboratory. Choice D is also incorrect as documenting the time the client last ate or drank is not directly relevant to the immediate action needed for the sputum sample.
3. The nurse is caring for a newborn with a myelomeningocele. Before surgery, what should the nursing interventions include?
- A. Leaving the lesion uncovered and placing the infant supine
- B. Covering the lesion with a sterile, saline-soaked gauze
- C. Applying lotion to the lesion to keep it moist
- D. Covering the lesion with a dry, sterile gauze
Correct answer: B
Rationale: The correct intervention before surgery for a newborn with a myelomeningocele is to cover the lesion with a sterile, saline-soaked gauze. This helps protect the exposed spinal cord and meninges from infection and damage. Choice A is incorrect because leaving the lesion uncovered can increase the risk of infection. Choice C is incorrect because applying lotion can introduce contaminants to the lesion. Choice D is incorrect because covering the lesion with a dry gauze can lead to adherence of the gauze to the wound, causing trauma upon removal and disrupting the healing process.
4. During an IV catheter insertion demonstration, which statement by a nurse indicates understanding of the procedure?
- A. “I will thread the needle into the vein at an angle of 10 to 30 degrees with the bevel up.”
- B. “I will insert the needle into the client’s skin at an angle of 10 to 30 degrees with the bevel up.”
- C. “I will apply pressure approximately 1.2 inches below the insertion site before removing the needle.”
- D. “I will select a vein in the antecubital fossa for IV insertion based on its size and easily accessible location.”
Correct answer: B
Rationale: The correct technique for IV catheter insertion involves inserting the needle at a 10 to 30-degree angle with the bevel up. This angle facilitates proper vein puncture, reduces the risk of complications, and minimizes trauma to the vein. Choice A is incorrect because threading the needle into the vein at an angle of 10 to 30 degrees with the bevel up is the correct technique, not threading it all the way into the vein. Choice C is incorrect because applying pressure 1.2 inches below the insertion site before removing the needle is not a standard step in IV catheter insertion. Choice D is incorrect because selecting the antecubital fossa vein solely based on its size and accessibility may not be the most appropriate criterion; vein selection should also consider factors like vein condition and patient comfort.
5. At a support meeting of parents of a teenager with polysubstance dependency, a parent states, 'Each time my son tries to quit taking drugs, he gets so depressed that I'm afraid he will commit suicide.' The nurse's response should be based on which information?
- A. Addiction is a chronic, incurable disease.
- B. Tolerance to the effects of drugs causes feelings of depression.
- C. Feelings of depression frequently lead to drug abuse and addiction.
- D. Careful monitoring should be provided during withdrawal from the drugs.
Correct answer: C
Rationale: The correct response in this situation should focus on the connection between feelings of depression and drug abuse. Choice A is incorrect because addiction is treatable, not incurable. Choice B is incorrect as tolerance does not directly cause depression. Choice D is not the best response as the parent's concern is about the son's depression leading to suicidal thoughts, not just the withdrawal process.