HESI RN
Mental Health HESI Quizlet
1. A client with a history of bipolar disorder is exhibiting symptoms of mania. Which intervention is most appropriate for the nurse to implement?
- A. Encourage the client to participate in group therapy.
- B. Provide a calm and structured environment.
- C. Limit stimulation and set firm limits on behavior.
- D. Promote self-care and hygiene practices.
Correct answer: C
Rationale: When a client with bipolar disorder is experiencing symptoms of mania, the most appropriate intervention for the nurse is to limit stimulation and set firm limits on behavior. This approach helps in managing the manic episode by preventing further escalation. Encouraging participation in group therapy (Choice A) may not be effective during the acute phase of mania, as the client may have difficulty focusing or following group discussions. Providing a calm and structured environment (Choice B) is beneficial, but setting firm limits is crucial to managing the impulsivity and risky behaviors associated with mania. Promoting self-care practices (Choice D) is important, but during a manic episode, setting limits and reducing stimuli take precedence over hygiene practices.
2. Outlet of the true pelvis anteriorly bounded by:
- A. Ischiopubic arch (T)
- B. Linea terminalis (F)
- C. Coccyx (T)
- D. Promontory of the sacrum (F)
Correct answer: A
Rationale: The correct answer is A: Ischiopubic arch. The outlet of the true pelvis is indeed anteriorly bounded by the ischiopubic arch, which consists of the ischium and the pubic bones. This structure forms the lower boundary of the pelvic outlet. The other choices, B, C, and D, are incorrect. The linea terminalis (pelvic brim) forms the upper boundary of the true pelvis, the coccyx is part of the bony pelvis but does not bound the pelvic outlet anteriorly, and the promontory of the sacrum is located in the posterior part of the pelvis, not the anterior boundary of the pelvic outlet.
3. After breastfeeding for 10 minutes at each breast, a new mother calls the nurse to the postpartum room to help change the newborn's diaper. As the mother begins the diaper change, the newborn spits up the breast milk. What action should the nurse implement first?
- A. Wipe away the spit-up and assist the mother with the diaper change.
- B. Sit the newborn upright and burp by rubbing or patting the upper back.
- C. Place the newborn in a position with the head lower than the feet.
- D. Turn the newborn to the side and use bulb suction for the mouth and nares.
Correct answer: B
Rationale: After a newborn spits up breast milk following feeding, the priority action for the nurse is to sit the newborn upright and burp by rubbing or patting the upper back. This position helps release trapped air and reduces the likelihood of further spit-up or aspiration. It is essential to address this first to prevent potential complications and ensure the newborn's comfort and safety.
4. Protein synthesis begins with a process known as transcription. Where does this process occur?
- A. In the cytoplasm
- B. In the nuclear envelope
- C. In the ribosome unit
- D. In the nucleus
Correct answer: D
Rationale: The correct answer is D: In the nucleus. Transcription, the initial step of protein synthesis, takes place in the nucleus where DNA is transcribed into mRNA. This mRNA then leaves the nucleus and enters the cytoplasm where translation occurs on the ribosomes. Choices A, B, and C are incorrect because transcription specifically occurs in the nucleus, not in the cytoplasm, nuclear envelope, or ribosome unit.
5. A 6-month-old child who had a cleft-lip repair has elbow restraints in place. What nursing intervention should the nurse plan to implement?
- A. Obtain the healthcare provider’s advice as to when the restraints should be removed.
- B. Remove restraints one at a time to provide range of motion exercises.
- C. Record observation of the restraints q2h and ensure that they are in place at all times.
- D. Remove restraints q4h for 30 minutes and place gloves on the child’s hands.
Correct answer: B
Rationale: Removing restraints one at a time for range of motion exercises prevents muscle stiffness and allows assessment of the skin.