HESI RN
Quizlet Mental Health HESI
1. A client with an eating disorder is being treated in a behavioral health unit. Which behavior would the nurse expect to see if the client is responding positively to the treatment?
- A. Adherence to the treatment plan and increased self-care activities.
- B. Increased isolation from others.
- C. Frequent complaining about treatment procedures.
- D. Refusal to eat meals provided by the unit.
Correct answer: A
Rationale: A positive response to treatment for a client with an eating disorder is indicated by adherence to the treatment plan and an increase in self-care activities. These behaviors show that the client is actively engaging in their treatment and taking steps towards recovery. Option B, increased isolation from others, is not indicative of a positive response to treatment as it may suggest withdrawal or avoidance. Option C, frequent complaining about treatment procedures, is not a behavior that signifies a positive response; it may indicate dissatisfaction or discomfort with the treatment. Option D, refusal to eat meals provided by the unit, is also not a positive response as it could suggest continued resistance to treatment and potential worsening of symptoms.
2. A client is admitted with a diagnosis of diabetic ketoacidosis (DKA). Which clinical finding is most concerning to the nurse?
- A. Kussmaul respirations
- B. Blood glucose level of 300 mg/dl
- C. Serum potassium of 3.2 mEq/L
- D. Positive urine ketones
Correct answer: C
Rationale: The correct answer is C: Serum potassium of 3.2 mEq/L. A low serum potassium level in a client with DKA is concerning due to the risk of cardiac arrhythmias. Kussmaul respirations (choice A) are a compensatory mechanism for metabolic acidosis in DKA. A blood glucose level of 300 mg/dl (choice B) is elevated but expected in DKA. Positive urine ketones (choice D) are a classic finding in DKA and not as concerning as low serum potassium.
3. A nurse is caring for a client who is receiving morphine sulfate via a patient-controlled analgesia (PCA) pump. Which action is most important for the nurse to implement?
- A. Monitor the client's respiratory status
- B. Teach the client how to use the PCA pump
- C. Evaluate the client's pain level
- D. Assess the client's pain level
Correct answer: A
Rationale: When a client is receiving opioids like morphine sulfate via a PCA pump, the most critical action for the nurse to implement is to monitor the client's respiratory status. Opioids can cause respiratory depression, which can be life-threatening. Monitoring respiratory status allows for early detection of any signs of respiratory compromise. Teaching the client how to use the PCA pump, evaluating pain level, and assessing pain level are important aspects of care but ensuring the client's safety by monitoring respiratory status takes precedence due to the potential risks associated with opioid administration.
4. During a routine clinic visit, a nurse is assessing a 48-year-old client with a history of smoking. The client, who exercises regularly, reports calf pain during exercise that disappears at rest. Which of the following findings requires further evaluation?
- A. Heart rate of 57 bpm.
- B. SpO2 of 94% on room air.
- C. Blood pressure of 134/82.
- D. Ankle-brachial index of 0.65.
Correct answer: D
Rationale: An Ankle-Brachial Index of 0.65 suggests moderate arterial vascular disease in a client experiencing intermittent claudication, indicating compromised blood flow to the lower extremities during exercise. This finding requires further evaluation to assess the severity of arterial insufficiency and determine appropriate interventions. Choice A (Heart rate of 57 bpm) is within the normal range for an adult at rest and indicates good cardiovascular fitness. Choice B (SpO2 of 94% on room air) is slightly lower than the normal range but is generally acceptable in a healthy individual. Choice C (Blood pressure of 134/82) falls within the normal range and does not raise immediate concerns in this context.
5. The nurse provides medication instructions to an older hypertensive client who is taking 20 mg of lisinopril (Prinivil, Zestril) orally daily. The nurse evaluates the need for further teaching when the client states which of the following?
- A. I can skip a dose once a week.
- B. I need to change my position slowly.
- C. I take the pill after breakfast each day.
- D. If I get a bad headache, I should call my doctor immediately.
Correct answer: A
Rationale: Lisinopril should be taken daily as prescribed and not skipped. Skipping doses can lead to ineffective treatment.