HESI LPN
Mental Health HESI Practice Questions
1. A client with schizophrenia is being treated with haloperidol (Haldol). The client reports feeling restless and unable to sit still. What should the nurse do first?
- A. Instruct the client to take deep breaths and relax.
- B. Assess the client for signs of akathisia.
- C. Encourage the client to engage in physical activity.
- D. Administer a PRN dose of lorazepam (Ativan).
Correct answer: B
Rationale: Restlessness and inability to sit still are signs of akathisia, an extrapyramidal side effect of antipsychotic medications. The nurse should first assess the client for signs of akathisia by observing their movements and behavior. Assessing for akathisia is crucial to differentiate it from other conditions and to intervene appropriately. Instructing the client to relax or engage in physical activity may not address the underlying issue of akathisia. Administering lorazepam should not be the first action as it may mask the symptoms of akathisia temporarily without addressing the root cause.
2. A client with Guillain-Barre syndrome is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?
- A. Comatose, breathing unlabored
- B. Glasgow Coma Scale 8, respirations regular
- C. Appears to be sleeping, vital signs stable
- D. Glasgow Coma Scale 13, no ventilator required
Correct answer: B
Rationale: A client with Guillain-Barre syndrome in a non-responsive state with stable vital signs and independent breathing would most accurately be described by a Glasgow Coma Scale of 8 with regular respirations. Choice A is incorrect as 'comatose' implies a deeper level of unconsciousness than described in the scenario. Choice C is incorrect as 'appears to be sleeping' is not an accurate description of a non-responsive state. Choice D is incorrect as a Glasgow Coma Scale of 13 indicates a higher level of consciousness than stated in the scenario.
3. The client is being instructed on how to collect a clean catch urine specimen. Which sequence is appropriate for teaching?
- A. Void a little, clean the meatus, then collect specimen
- B. Clean the meatus, begin voiding, then catch urine stream
- C. Clean the meatus, then urinate into container
- D. Void continuously and catch some of the urine
Correct answer: B
Rationale: The correct sequence for obtaining a clean catch urine specimen involves first cleaning the meatus to prevent contamination, then initiating voiding to catch the midstream urine. This method ensures that the sample is as uncontaminated as possible, making choice B the correct sequence. Option A is incorrect as cleaning the meatus should be done before voiding. Option C is incorrect as it does not involve catching a midstream urine sample. Option D is incorrect as it suggests catching urine throughout the entire voiding process, which may lead to contamination.
4. A client with osteoporosis is prescribed raloxifene. The nurse should reinforce which instruction?
- A. Take this medication at the same time each day.
- B. Take this medication with a full glass of water.
- C. Take this medication on an empty stomach.
- D. Take this medication immediately after a meal.
Correct answer: A
Rationale: The correct instruction for a client prescribed raloxifene, a medication used for osteoporosis, is to take it at the same time each day. This consistency helps maintain steady blood levels of the medication, enhancing its effectiveness in managing the condition. Choice B is incorrect because raloxifene does not require a full glass of water for administration. Choice C is incorrect as raloxifene should not be taken on an empty stomach. Choice D is incorrect as raloxifene should not be taken immediately after a meal.
5. A client is scheduled for an abdominal ultrasound in the morning and has been instructed to fast overnight. The client asks the nurse why fasting is necessary. What is the best response?
- A. It helps reduce the production of intestinal gases.
- B. It ensures clearer imaging by emptying the stomach.
- C. It prevents the risk of aspiration during the procedure.
- D. It is a standard procedure for all surgical interventions.
Correct answer: B
Rationale: The correct answer is B: 'It ensures clearer imaging by emptying the stomach.' Fasting before an abdominal ultrasound is essential to empty the stomach, allowing for better visualization of the abdominal organs. This improves the quality of the imaging and enhances diagnostic accuracy. Choices A, C, and D are incorrect because reducing intestinal gases, preventing aspiration, and being a standard procedure for surgical interventions are not the primary reasons for fasting before an abdominal ultrasound.