HESI LPN
HESI Mental Health Practice Exam
1. A female client presents to the emergency center with confusion, emotional numbness, and expresses to the nurse a feeling of disbelief that she was raped. The nurse determines the client is in the acute phase of rape-trauma syndrome. What action should the nurse implement first?
- A. Secure samples of vaginal hair combings.
- B. Offer prophylactic antibiotic medication.
- C. Explain the rape protocol to the client.
- D. Implement crisis intervention counseling.
Correct answer: C
Rationale: In cases of rape-trauma syndrome, it is crucial to provide clear information about what to expect during the examination and treatment. This can help the client regain a sense of control and reduce anxiety. Explaining the rape protocol to the client should be the first action to implement. Option A is not the priority at this stage as the immediate focus is on addressing the client's emotional needs and providing support. Option B is not the first action unless medically indicated. Option D, crisis intervention counseling, is important but should come after providing essential information and support to the client.
2. A healthcare professional is reviewing the laboratory report of a child with tetralogy of Fallot that indicates an elevated RBC count. What does the professional identify as the cause of the polycythemia?
- A. Low tissue oxygen needs
- B. Tissue oxygen needs
- C. Diminished iron level
- D. Hypertrophic cardiac muscle
Correct answer: B
Rationale: The correct answer is B: Tissue oxygen needs. Polycythemia occurs as the body's response to chronic hypoxia by increasing RBC production to enhance oxygen delivery. In tetralogy of Fallot, a congenital heart defect, the heart's structure causes reduced oxygen levels in the blood. This chronic hypoxia stimulates the bone marrow to produce more red blood cells, leading to an elevated RBC count. Choice A is incorrect as low blood pressure is not directly related to polycythemia in this context. Choice C, diminished iron level, is not the cause of polycythemia in tetralogy of Fallot. Choice D, hypertrophic cardiac muscle, is not the primary cause of the elevated RBC count in this case.
3. A client comes into the community health center upset and crying stating, “I will die of cancer now that I have this disease.” And then the client hands the nurse a paper with one word written on it: 'Pheochromocytoma.' Which response should the nurse state initially?
- A. 'Pheochromocytomas usually aren't cancerous (malignant). But they may be associated with cancerous tumors in other endocrine glands such as the thyroid (medullary carcinoma of the thyroid).'
- B. 'This problem is diagnosed by blood and urine tests that reveal elevated levels of adrenaline and noradrenaline.'
- C. 'Computerized tomography (CT) or magnetic resonance imaging (MRI) are used to detect an adrenal tumor.'
- D. 'You probably have had episodes of sweating, heart pounding, and headaches.'
Correct answer: A
Rationale: The correct initial response for the nurse to provide in this situation is to offer reassurance. Stating that 'Pheochromocytomas usually aren't cancerous (malignant)' helps to alleviate the client's anxiety and fear of having cancer. This response also establishes a foundation for further discussion about the condition, allowing the nurse to address the client's concerns and provide accurate information. Choice B is incorrect as it focuses solely on the diagnostic tests for pheochromocytoma but does not address the client's emotional distress. Choice C is incorrect as it discusses imaging modalities without directly addressing the client's concerns. Choice D is also incorrect as it assumes symptoms without first addressing the client's emotional state and fear of cancer.
4. A client has a prescription for heparin 1,000 units IV STAT. Several pre-filled syringes of low molecular weight heparin are available in the client's medication drawer. Which action should the nurse implement?
- A. Dilute the available heparin in 250ml of normal saline solution prior to IV administration
- B. Advise the pharmacy on the need to deliver a vial of heparin to the nursing unit immediately
- C. Calculate and administer the equivalent dose of the available low molecular weight heparin
- D. Request a prescription to change the route of administration and use the available heparin
Correct answer: B
Rationale: In this scenario, the nurse should contact the pharmacy to obtain the correct heparin formulation as the prescription calls for heparin 1,000 units IV STAT. Low molecular weight heparin is not the same as unfractionated heparin, and therefore, the nurse should not administer the available low molecular weight heparin without first obtaining the correct medication. Diluting the available heparin, calculating an equivalent dose, or changing the route of administration would not address the discrepancy between the prescribed heparin and the available low molecular weight heparin.
5. The nurse is providing oral care to a patient. In which order will the nurse clean the oral cavity, starting with the first area?
- A. Roof of mouth, gums, and inside cheeks
- B. Chewing and inner tooth surfaces
- C. Outer tooth surfaces
- D. Tongue
Correct answer: C
Rationale: The correct sequence for oral care is to clean the outer tooth surfaces first, followed by cleaning the inner tooth surfaces, then the roof of the mouth, gums, and inside cheeks with a toothette. Brushing the tongue should be the final step in the oral care procedure. Therefore, option C is the correct choice. Options A, B, and D are incorrect because they do not follow the correct order for providing oral care to a patient.