HESI RN
Quizlet Mental Health HESI
1. A client is admitted for bipolar disorder and alcohol withdrawal, depressive phase. Based on which assessment finding will the RN withhold the clonidine (Catapres) prescription?
- A. Blood pressure readings of 90/62 mmHg to 92/58 mmHg.
- B. Pulse rate of 68-78 BPM.
- C. Temperature of 99.5-99.7°F.
- D. Respiration rate of 24 breaths per minute.
Correct answer: A
Rationale: In this scenario, the correct answer is A. Clonidine, such as Catapres, is a medication that can lower blood pressure. Therefore, if a client has low blood pressure readings, like 90/62 mmHg to 92/58 mmHg, the registered nurse should withhold the clonidine prescription to prevent further lowering of blood pressure which could lead to adverse effects. Choices B, C, and D are incorrect because they are within normal ranges and do not present a contraindication for the administration of clonidine in this context.
2. When culturing a wound, the nurse should obtain the sample from which part of the wound?
- A. The outer edges of the wound.
- B. All necrotic sections of the wound.
- C. Areas containing purulent or pooled exudates.
- D. Any particularly painful area of the wound.
Correct answer: C
Rationale: To collect a wound culture, the nurse should first clean the wound to remove skin flora and then insert a sterile swab from a culturette tube into the wound secretions.
3. What principle about patient-nurse communication should guide a nurse's fear of 'saying the wrong thing' to a patient?
- A. Patients tend to appreciate a well-meaning person who conveys genuine acceptance, respect, and concern for their situation.
- B. The patient is more interested in talking to you than listening to what you have to say and is not likely to be offended.
- C. Considering the patient's history, there is little chance that the comment will do any actual harm.
- D. Most people with a mental illness have by necessity developed a high tolerance for forgiveness.
Correct answer: A
Rationale: The correct principle guiding nurse-patient communication is that patients value genuine acceptance, respect, and concern. Choice A is the correct answer because showing genuine care and concern for the patient's situation fosters a positive and therapeutic relationship. Choice B is incorrect as effective communication involves active listening and responding appropriately, not assuming the patient is only interested in talking. Choice C is incorrect because a patient's history does not guarantee immunity to harm from inappropriate comments. Choice D is incorrect as it generalizes individuals with mental illness and forgiveness, which is not directly related to communication fears.
4. A client with a history of heart failure is admitted with severe dyspnea. Which intervention should the nurse implement first?
- A. Administer oxygen at 2 liters per minute via nasal cannula.
- B. Place the client in a high Fowler's position.
- C. Obtain a 12-lead electrocardiogram (ECG).
- D. Administer intravenous furosemide (Lasix).
Correct answer: B
Rationale: The correct answer is to place the client in a high Fowler's position first. This intervention helps improve breathing and oxygenation in clients with severe dyspnea, including those with heart failure. Elevating the head of the bed reduces the work of breathing and enhances lung expansion. Administering oxygen, obtaining an ECG, and administering furosemide are important interventions in the management of heart failure, but placing the client in a high Fowler's position is the priority to address the immediate need for improved breathing and oxygenation.
5. When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes that this is the first time the client has voided in 4 hours. Which action should the nurse take next?
- A. Record the amount on the client's fluid output record.
- B. Encourage the client to increase oral fluid intake.
- C. Notify the healthcare provider of the findings.
- D. Palpate the client's bladder for distention.
Correct answer: A
Rationale: The nurse should record the amount on the client's fluid output record because the 350 mL of pale yellow urine is a normal finding. This indicates appropriate urine output, so encouraging increased fluid intake or notifying the healthcare provider is not necessary at this time. Additionally, palpating the client's bladder for distention is not indicated based on the normal urine output observed.