HESI RN
Mental Health HESI
1. A client who has agoraphobia (a fear of crowds) is starting desensitization therapy with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care?
- A. Encourage the substitution of positive thoughts for negative ones.
- B. Establish trust by providing a calm, safe environment.
- C. Gradually expose the client to larger crowds.
- D. Encourage deep breathing when anxiety escalates in a crowd.
Correct answer: B
Rationale: Establishing trust by providing a calm and safe environment is crucial for the success of desensitization therapy in clients with agoraphobia. This approach helps the client feel safe and secure, allowing them to gradually confront their fear of crowds. Encouraging positive thoughts (choice A) is beneficial but not as immediately critical as creating a safe space. Progressively exposing the client to larger crowds (choice C) should occur after trust is established and in a controlled manner. Encouraging deep breathing (choice D) is helpful, but creating a safe environment takes precedence to build a foundation for successful desensitization.
2. A client with Alzheimer's disease is exhibiting signs of agitation and aggression. What is the nurse's priority intervention?
- A. Reassure the client and provide emotional support.
- B. Redirect the client to a quiet activity.
- C. Administer a PRN dose of lorazepam.
- D. Apply soft restraints as needed to prevent harm.
Correct answer: B
Rationale: The correct answer is to redirect the client to a quiet activity. This intervention helps reduce agitation and aggression in clients with Alzheimer's disease by providing a distraction and promoting a calming environment. Reassuring the client and providing emotional support (Choice A) can be beneficial but is not the priority in this situation. Administering a PRN dose of lorazepam (Choice C) should not be the first intervention due to the risk of adverse effects and should only be considered if other non-pharmacological interventions are ineffective. Applying restraints (Choice D) should be avoided unless absolutely necessary for the client's safety as it can lead to further distress and is not the initial priority intervention.
3. During a follow-up home visit, the nurse observes that a client with chronic obstructive pulmonary disease (COPD) is using accessory muscles to breathe and has a pulse oximetry reading of 88%. What action should the nurse take first?
- A. Administer a prescribed bronchodilator
- B. Increase the oxygen flow rate
- C. Instruct the client to perform pursed-lip breathing
- D. Notify the healthcare provider immediately
Correct answer: C
Rationale: In this situation, the nurse should first instruct the client to perform pursed-lip breathing. Pursed-lip breathing helps improve oxygenation and decrease the work of breathing in clients with COPD. Administering a bronchodilator or increasing the oxygen flow rate may be necessary interventions but addressing the breathing technique through pursed-lip breathing is the initial action to optimize oxygenation. Notifying the healthcare provider immediately is not the first action indicated in this scenario; the nurse should intervene promptly to assist the client in improving breathing before escalating the situation.
4. The client with Addison's disease is receiving education on managing the condition. Which of the following instructions should be included?
- A. Increase your sodium intake during periods of stress.
- B. Avoid all types of exercise.
- C. Decrease your fluid intake to prevent fluid overload.
- D. Stop corticosteroid therapy once symptoms improve.
Correct answer: A
Rationale: The correct instruction to include for a client with Addison's disease is to increase sodium intake during periods of stress. In Addison's disease, there is a deficiency of aldosterone leading to sodium loss. Increasing sodium intake helps to compensate for this loss and prevent complications. Choice B is incorrect as exercise is beneficial for overall health but should be done in moderation. Choice C is incorrect as fluid intake should be adequate to prevent dehydration since clients with Addison's disease are prone to electrolyte imbalances. Choice D is incorrect as corticosteroid therapy is essential for managing Addison's disease and should not be discontinued abruptly without medical guidance.
5. Which task can the registered nurse (RN) caring for a critically ill patient with multiple IV lines delegate to an experienced licensed practical/vocational nurse (LPN/LVN)?
- A. Administer IV antibiotics through the implantable port.
- B. Monitor the IV sites for redness, swelling, or tenderness.
- C. Remove the patient’s nontunneled subclavian central venous catheter.
- D. Adjust the flow rate of the 0.9% normal saline in the peripheral IV line.
Correct answer: B
Rationale: An experienced LPN/LVN can monitor IV sites for signs of infection because it falls within their education, experience, and scope of practice. Administering IV antibiotics through an implantable port, adjusting infusion rates, and removing central catheters are tasks that require RN level education and scope of practice. These activities involve a higher level of assessment, critical thinking, and potential complications that are typically within the RN's domain.