HESI RN
Quizlet Mental Health HESI
1. A female client engages in repeated checks of door and window locks, behavior that prevents her from arriving on time and interferes with her ability to function effectively. What action should the nurse take?
- A. Discuss why the client checks the locks frequently
- B. Ask the client why she checks the locks
- C. Plan a daily list of activities to be carried out
- D. Determine the type and size of the locks
Correct answer: B
Rationale: The correct action for the nurse to take is to ask the client why she checks the locks. By doing so, the nurse can help the client gain insight into the underlying anxiety that drives this behavior and assist her in developing new adaptive coping strategies. Choice A is not as effective as directly asking the client about her behavior. Choice C focuses on planning activities but does not address the root cause of the client's behavior. Choice D is irrelevant to addressing the client's repeated checking behavior.
2. A school nurse is developing a health risk screening protocol for use at an elementary school. What information is most important for the nurse to include in this protocol?
- A. annual flu vaccination status
- B. weight and height measurement
- C. total cholesterol level
- D. long bone deformity testing
Correct answer: B
Rationale: Weight and height measurements are crucial components of health screenings in children as they help assess growth patterns and identify potential health concerns such as obesity or growth disorders. Monitoring weight and height regularly can aid in early intervention and prevention of health issues. Annual flu vaccination status, total cholesterol level, and long bone deformity testing are not typically primary components of routine health screenings in elementary school children and may not directly contribute to identifying common health risks in this population.
3. A client with urticaria due to environmental allergies is taking diphenhydramine. Which complaint should the nurse identify as a side effect of the OTC medication?
- A. Nausea and indigestion.
- B. Hypersalivation.
- C. Eyelid and facial twitching.
- D. Increased appetite.
Correct answer: A
Rationale: The correct answer is A: Nausea and indigestion. Diphenhydramine, an antihistamine, commonly causes gastrointestinal side effects such as nausea and indigestion. This medication can have anticholinergic effects, leading to these symptoms. Choices B, C, and D are incorrect because hypersalivation, eyelid and facial twitching, and increased appetite are not typically associated with diphenhydramine use.
4. A client has lost a significant amount of blood due to complications during surgery. What parameter does the nurse recognize as the earliest indication of new decreases in fluid volume?
- A. Pulse rate
- B. Blood pressure
- C. Pulmonary artery systolic pressure
- D. Pulmonary artery end-diastolic pressure
Correct answer: A
Rationale: The earliest indication of new decreases in fluid volume is often recognized by an increase in pulse rate. Cardiac output is influenced by circulating blood volume, heart pumping action, and vascular tone. As fluid volume decreases, the body compensates by increasing the pulse rate. The formula for cardiac output is pulse rate multiplied by stroke volume. An elevated pulse rate helps maintain blood pressure with minor volume depletion. Pulmonary artery systolic pressure and pulmonary artery end-diastolic pressure, obtained through a pulmonary artery catheter, provide insights into pulmonary artery and left ventricle pressures at the end of diastole. These parameters are not the earliest indicators of new decreases in fluid volume compared to pulse rate.
5. A 17-year-old adolescent reports flu-like symptoms and is brought to the emergency room. What intervention should the nurse implement first?
- A. Assess the client's temperature.
- B. Place a mask on the client.
- C. Obtain a chest X-ray per protocol.
- D. Determine the client's blood pressure.
Correct answer: B
Rationale: The correct answer is to place a mask on the client. This intervention is crucial in preventing the spread of infections like the flu, especially in a healthcare setting where the risk of transmission is high. Assessing the client's temperature (Choice A) can be important but is not the priority in this situation. Obtaining a chest X-ray (Choice C) and determining the client's blood pressure (Choice D) are not the immediate interventions needed for a 17-year-old reporting flu-like symptoms.