HESI RN
Mental Health HESI Quizlet
1. A client on the mental health unit is becoming more agitated, shouting at the staff, and pacing in the hallway. When a PRN medication is offered, the client refuses the medication and defiantly sits on the floor in the middle of the unit hallway. What nursing intervention should the nurse implement first?
- A. Transport the client to the seclusion room.
- B. Quietly approach the client with additional staff members.
- C. Take other clients in the area to the client lounge.
- D. Administer medication to chemically restrain the client.
Correct answer: B
Rationale: In situations where a client is agitated and refusing medication, a non-confrontational approach with additional staff can help de-escalate the situation and address the client's behavior safely. Transporting the client to the seclusion room (Choice A) should not be the initial intervention unless the client poses an immediate risk of harm to themselves or others. Taking other clients to the client lounge (Choice C) does not directly address the agitated client's behavior. Administering medication to chemically restrain the client (Choice D) should only be considered after other de-escalation attempts have been made and if there is a significant safety concern.
2. A female client has been taking a high dose of prednisone, a corticosteroid, for several months. After stopping the medication abruptly, the client reports feeling 'very tired'. Which nursing intervention is most important for the nurse to implement?
- A. Measure vital signs
- B. Auscultate breath sounds
- C. Palpate the abdomen
- D. Observe the skin for bruising
Correct answer: A
Rationale: The correct answer is to measure vital signs. Abrupt withdrawal of exogenous corticosteroids can precipitate adrenal insufficiency, potentially leading to shock. Monitoring vital signs is crucial in identifying any signs of adrenal insufficiency, such as hypotension or tachycardia. Auscultating breath sounds (choice B) may be important in other situations, such as respiratory conditions, but it is not the priority in this case. Palpating the abdomen (choice C) and observing the skin for bruising (choice D) are not directly related to the potential complications of corticosteroid withdrawal and adrenal insufficiency.
3. A client has been given a prescription for tetracycline HCL (Sumycin). The nurse should emphasize the client to
- A. Take the medication with food or milk
- B. Avoid prolonged sun exposure
- C. Monitor for signs of yellowing skin or eyes
- D. Expect a yellow-brown discoloration of the teeth
Correct answer: C
Rationale: The correct answer is C: 'Monitor for signs of yellowing skin or eyes.' Tetracycline can cause hepatotoxicity, leading to jaundice which may present as yellowing of the skin or eyes. This is a serious side effect that the nurse should emphasize to the client. Choice A is incorrect because tetracycline should generally be taken on an empty stomach, not with food or milk. Choice B is also incorrect as tetracycline can cause photosensitivity, but it is not directly related to yellowing skin or eyes. Choice D is incorrect because tetracycline can cause yellow-brown discoloration of the teeth, but this is usually seen in children under 8 years of age, not a common concern for adult clients.
4. Why is the combination drug trimethoprim-sulfamethoxazole (TMP-SMX) necessary?
- A. To broaden the antibacterial spectrum.
- B. To decrease bacterial resistance.
- C. To improve the taste.
- D. To minimize toxic effects.
Correct answer: B
Rationale: The correct answer is B: To decrease bacterial resistance. Trimethoprim-sulfamethoxazole (TMP-SMX) is a combination drug used to prevent bacterial resistance to sulfonamides. It works by targeting different steps in the bacterial metabolic pathway, making it harder for bacteria to develop resistance. Choice A is incorrect because the combination does not broaden the antibacterial spectrum; instead, it enhances effectiveness against specific bacteria. Choice C is incorrect as taste improvement is not the primary reason for combining these drugs. Choice D is incorrect because while combination therapy can sometimes help minimize toxic effects, the primary purpose in this case is to address bacterial resistance.
5. A client with chronic obstructive pulmonary disease (COPD) is experiencing dyspnea. Which of these actions should the nurse perform first?
- A. Administer oxygen therapy
- B. Encourage the client to perform deep breathing exercises
- C. Raise the head of the bed
- D. Check the client's oxygen saturation level
Correct answer: D
Rationale: The correct answer is to check the client's oxygen saturation level first. This action is crucial in assessing the severity of dyspnea and determining the necessity for oxygen therapy. Administering oxygen therapy without knowing the current oxygen saturation level can be inappropriate and potentially harmful. Encouraging deep breathing exercises and raising the head of the bed are important interventions, but assessing the oxygen saturation level takes precedence in managing dyspnea in a client with COPD.