HESI LPN
HESI Mental Health
1. A client who is being treated with lithium carbonate for bipolar disorder develops diarrhea, vomiting, and drowsiness. What action should the LPN/LVN take?
- A. Notify the healthcare provider immediately and prepare for administration of an antidote.
- B. Notify the healthcare provider of the symptoms prior to the next administration of the drug.
- C. Record the symptoms as normal side effects and continue administration of the prescribed dosage.
- D. Hold the medication and refuse to administer additional amounts of the drug.
Correct answer: B
Rationale: When a client being treated with lithium carbonate for bipolar disorder develops symptoms like diarrhea, vomiting, and drowsiness, it could indicate lithium toxicity. The appropriate action for the LPN/LVN is to notify the healthcare provider immediately of these symptoms before the next administration of the drug. This prompt communication is crucial to ensure that the healthcare provider can assess the situation, adjust the treatment plan if necessary, and prevent potential complications associated with lithium toxicity. Option A is incorrect because administering an antidote should be based on the healthcare provider's assessment. Option C is incorrect as these symptoms are not normal side effects and could indicate a serious issue. Option D is incorrect because refusing to administer the drug without consulting the healthcare provider could delay necessary interventions.
2. A 20-year-old female client with schizophrenia is scheduled to receive risperidone (Risperdal) 2mg at bedtime. When the nurse attempts to administer the medication, the client states, 'I am not going to take that medicine, and you can't make me.' What action should the nurse take?
- A. Administer the medication via a nasogastric tube.
- B. Substitute an injectable form of the medication.
- C. Encourage the client to take the medicine because it will help her sleep.
- D. Document in the client's record that the medication was refused.
Correct answer: D
Rationale: In this scenario, the correct action for the nurse to take is to respect the client's autonomy and decision-making capacity. It's crucial to document the medication refusal accurately in the client's record. Administering the medication via a nasogastric tube or substituting it with an injectable form would violate the client's right to refuse treatment and should only be considered in extreme cases after consulting with the healthcare team. Encouraging the client to take the medication because it will help her sleep disregards her autonomy and choice in the matter.
3. When reinforcing diet teaching for a client diagnosed with hypokalemia, which foods should the PN encourage the client to eat? Select All That Apply
- A. Orange juice, oranges, bananas
- B. All are applicable
- C. Collard greens, kale, turnips
- D. Soybeans, lima beans, spinach
Correct answer: B
Rationale: The correct answer is B: All are applicable. Foods rich in potassium, such as orange juice, oranges, bananas, collard greens, kale, soybeans, lima beans, and spinach, are essential for managing hypokalemia. These options provide a significant source of potassium, which helps in maintaining normal heart and muscle function. Choice A is incorrect because it does not include all the appropriate potassium-rich foods. Choice C is incorrect as it only mentions vegetables rich in potassium, missing out on other essential sources like fruits and beans. Choice D is incorrect as it lacks key potassium-rich foods like oranges and bananas.
4. A client with a severe peanut allergy accidentally ingested peanut-containing food and is experiencing anaphylaxis. What is the nurse's priority action?
- A. Administer an epinephrine injection
- B. Call for immediate medical help
- C. Monitor airway, breathing, and circulation
- D. All of the above
Correct answer: A
Rationale: The priority action for a client experiencing anaphylaxis due to a severe peanut allergy is to administer an epinephrine injection. Epinephrine is the first-line treatment for anaphylaxis as it can rapidly reverse the severe allergic reaction. While calling for immediate medical help is important, administering epinephrine takes precedence because it can be life-saving in this situation. Monitoring airway, breathing, and circulation is essential in managing anaphylaxis, but administering epinephrine is the priority action to halt the progression of the allergic reaction and stabilize the client's condition. Therefore, 'Administer an epinephrine injection' is the most critical initial intervention.
5. When administering parenteral iron, which action would be inconsistent with proper administration?
- A. Using the Z-track method
- B. Using an air bubble to avoid withdrawing medication into subcutaneous tissue
- C. Not massaging the injection site
- D. Using the deltoid muscle for administration
Correct answer: D
Rationale: The correct answer is D: Using the deltoid muscle for administration. Administering parenteral iron in the deltoid muscle is not recommended due to the risk of irritation and pain. The Z-track method (choice A) is preferred to prevent staining and irritation of the skin when administering irritating medications like iron. Using an air bubble (choice B) to avoid withdrawing medication into subcutaneous tissue is a common practice to ensure accurate administration. Not massaging the injection site (choice C) is also a standard practice to prevent potential irritation or bleeding at the injection site.