HESI RN
Mental Health HESI
1. A client is admitted to the mental health unit and reports taking extra antianxiety medication because, “I’m so stressed out. I just wanted to go sleep.” The nurse should plan one-on-one observation of the client based on which statement?
- A. What should I do? Nothing seems to help.
- B. I have been so tired lately and needed to sleep.
- C. I really think that I don’t need to be here.
- D. I don’t want to talk. Nothing matters anymore.
Correct answer: D
Rationale: The client's statement of not wanting to talk and feeling that nothing matters anymore is indicative of severe depression or a risk for self-harm. This warrants immediate attention and one-on-one observation to ensure the client's safety. Choices A, B, and C do not express the same level of concerning behavior and do not imply an immediate risk to the client's well-being.
2. The nurse is preparing a teaching plan for a client diagnosed with asthma. The primary purpose of the plan is to
- A. Prevent respiratory infections
- B. Prevent airway inflammation
- C. Maintain an open airway
- D. Avoid allergens that trigger attacks
Correct answer: D
Rationale: Avoiding allergens that trigger asthma attacks is crucial in managing the condition and preventing exacerbations. While preventing respiratory infections and maintaining an open airway are important aspects of asthma management, the primary focus of the teaching plan is to help the client identify and avoid allergens that could trigger asthma attacks. This proactive approach can significantly reduce the frequency and severity of asthma symptoms.
3. Which of the following options correctly lists the five stages of mitosis in order from beginning to end?
- A. Prophase, Prometaphase, Telophase, Metaphase, Anaphase
- B. Prophase, Prometaphase, Metaphase, Anaphase, Telophase
- C. Metaphase, Anaphase, Prophase, Prometaphase, Telophase
- D. Metaphase, Telophase, Anaphase, Prophase, Prometaphase
Correct answer: B
Rationale: The correct order of the stages of mitosis is Prophase, Prometaphase, Metaphase, Anaphase, and Telophase. Choice A is incorrect because it has Anaphase and Metaphase in the wrong order. Choice C is incorrect as it starts with Metaphase, which is not the first stage of mitosis. Choice D is incorrect as it also has the stages in the wrong order, and it starts with Metaphase, which is incorrect.
4. A client with a history of calcium phosphate urinary stones is being taught by a nurse. Which statements should the nurse include in this client’s dietary teaching? (Select all that apply.)
- A. Limit your intake of food high in animal protein.
- B. Read food labels to help minimize your sodium intake.
- C. A and B
- D. Reduce your intake of milk and other dairy products.
Correct answer: C
Rationale: For a client with a history of calcium phosphate urinary stones, it is essential to limit the intake of foods high in animal protein to prevent the formation of stones. Additionally, reducing sodium intake is crucial as high sodium levels can contribute to stone formation. Therefore, choices A and B are correct. Choice D, which suggests reducing intake of milk and other dairy products, is not specifically recommended for calcium phosphate stones. Clients with calcium phosphate stones should focus on limiting animal protein, sodium, and calcium intake. Choices A and B address these dietary modifications, making them the correct options for this client. Choices D, which is not directly related to calcium phosphate stones, is incorrect.
5. A client is receiving IV fluid therapy for dehydration. Which assessment finding indicates that the client's fluid status is improving?
- A. Urine output increases to 50 mL/hour
- B. Client reports feeling more thirsty
- C. Blood pressure decreases from 120/80 to 110/70
- D. Heart rate increases from 80 to 100 beats per minute
Correct answer: A
Rationale: An increase in urine output is a positive sign that the client's hydration status is improving. It indicates that the kidneys are functioning well and that fluid therapy is effective. Increased urine output helps to eliminate excess fluid and waste products from the body. Choices B, C, and D are incorrect. Feeling more thirsty (choice B) is a sign of dehydration, not improvement. A decrease in blood pressure (choice C) and an increase in heart rate (choice D) are not typically indicative of improving fluid status during IV fluid therapy for dehydration.