HESI RN
Mental Health HESI Quizlet
1. What is the most appropriate intervention by the RN to address a client with obsessive-compulsive disorder (OCD) who repeatedly checks to see if the door is locked and asks for reassurance?
- A. Set a specific limit on the number of times the client can check the door.
- B. Help the client find an alternative activity to perform.
- C. Provide consistent reassurance that the door is locked.
- D. Ignore the checking behavior and focus on other behaviors.
Correct answer: A
Rationale: Setting a specific limit on the checking behavior is the most appropriate intervention for a client with OCD who repeatedly checks the door and seeks reassurance. This approach helps the client gradually reduce the compulsive behavior, promotes independence, and supports progress in treatment. Choice B is not the most suitable intervention as it does not directly address the compulsive checking behavior. Choice C, providing consistent reassurance, may reinforce the compulsive behavior and hinder treatment progress. Choice D of ignoring the behavior does not actively assist the client in managing their symptoms and addressing the underlying disorder.
2. An older adult client with heart failure (HF) and hypertension (HTN) is receiving atenolol, furosemide, and enalapril. Which assessments are essential to evaluate the effectiveness of the medications?
- A. Bowel sounds and daily weight.
- B. Daily weight and blood pressure.
- C. Heart sounds and range of motion.
- D. Monitor for evidence of hypokalemia.
Correct answer: B
Rationale: Monitoring daily weight and blood pressure is crucial to assess the effectiveness of diuretics (furosemide) and antihypertensives (atenolol, enalapril) in managing heart failure and hypertension. Changes in weight indicate fluid status, while blood pressure readings reflect the control of hypertension. Assessing bowel sounds and range of motion are important but not directly related to evaluating the effectiveness of these specific medications in this scenario. Monitoring for hypokalemia is important due to furosemide's potential side effect, but it is not the primary assessment to evaluate medication effectiveness.
3. A mother brings her 3-month-old infant to the clinic, concerned about frequent vomiting after feeding. The practical nurse (PN) suspects gastroesophageal reflux (GER). Which recommendation should the PN provide to the mother?
- A. Feed the infant in a prone position.
- B. Provide larger, less frequent feedings.
- C. Keep the infant upright for 30 minutes after feeding.
- D. Offer only formula thickened with rice cereal.
Correct answer: C
Rationale: The correct recommendation for reducing symptoms of gastroesophageal reflux (GER) in infants is to keep the infant upright for 30 minutes after feeding. This position helps prevent the backflow of stomach contents, alleviating symptoms of reflux. Placing the infant in a prone position or providing larger, less frequent feedings may worsen symptoms by increasing the likelihood of regurgitation. Offering only formula thickened with rice cereal is not the first-line intervention for GER and should not be recommended initially.
4. Which of the following Leopold maneuvers assesses the fetal lie?
- A. Fundal grip
- B. Umbilical grip
- C. Pawlick grip
- D. Pelvic grip
Correct answer: A
Rationale: The correct answer is A: Fundal grip. Fundal grip is a specific Leopold maneuver used to assess the fetal lie by palpating the upper abdomen to determine the position of the baby's back and presenting part. This maneuver helps healthcare providers understand the orientation of the fetus within the uterus. Choice B, Umbilical grip, is not a recognized Leopold maneuver and does not assess fetal lie. Choice C, Pawlick grip, and choice D, Pelvic grip, are also not part of the standard Leopold maneuvers used to determine fetal lie.
5. A client is diagnosed with hyperthyroidism. The nurse anticipates which of the following medications to be ordered?
- A. Levothyroxine
- B. Propylthiouracil
- C. Lithium
- D. Metoprolol
Correct answer: B
Rationale: The correct answer is B: Propylthiouracil. Propylthiouracil is an antithyroid medication used to manage hyperthyroidism by inhibiting the synthesis of thyroid hormones. Levothyroxine (Choice A) is typically used to treat hypothyroidism, the opposite of hyperthyroidism. Lithium (Choice C) is not used to treat hyperthyroidism but is commonly used to manage bipolar disorder. Metoprolol (Choice D) is a beta-blocker that may be used to manage symptoms like tachycardia associated with hyperthyroidism, but it is not the primary treatment for the condition.