HESI RN
Mental Health HESI
1. During the admission assessment, a female client requests that her husband be allowed to stay in the room. When the RN notes a discrepancy between the client’s verbal and nonverbal communication, what action should the RN take?
- A. Pay close attention to and document the nonverbal messages.
- B. Ask the client’s husband to interpret the discrepancy.
- C. Ignore the nonverbal behavior and focus solely on the client’s verbal messages.
- D. Integrate the verbal and nonverbal messages and interpret them together.
Correct answer: A
Rationale: During a client assessment, noting and documenting nonverbal messages is important as it captures the full context of the client’s communication. Nonverbal cues can often reveal underlying emotions or issues that may not be expressed verbally. Asking the client’s husband to interpret the discrepancy (Choice B) may not be appropriate as it could potentially breach the client's privacy and trust. Ignoring nonverbal behavior (Choice C) can result in missing important cues that could impact the care provided. Integrating verbal and nonverbal messages (Choice D) is beneficial, but the initial step should be to pay close attention and document the nonverbal messages to fully understand the client's communication.
2. An adult who has recurrent episodes of depression tells the nurse that the prescribed antidepressant needs to be discontinued because the client is feeling better after taking the medication for the past couple of weeks and does not like the side effects. Which response is best for the nurse to provide?
- A. Remind the client that feeling better is the therapeutic effect of the medication.
- B. Inform the client that gradual tapering must be used to discontinue the medication.
- C. Tell the client to discuss the medication side effects with the healthcare provider.
- D. Tell the client that the medication side effects will most likely diminish over time.
Correct answer: B
Rationale: The best response for the nurse is to inform the client that gradual tapering must be used to discontinue the medication. Abrupt cessation of antidepressants can lead to withdrawal symptoms or a recurrence of depressive symptoms. Choice A is not the best response as it does not address the need for a proper discontinuation plan. Choice C is not the best response as it focuses solely on the side effects and does not address the discontinuation process. Choice D is not the best response because while side effects may diminish over time, the focus here should be on the safe discontinuation of the medication to prevent adverse effects.
3. Which of the following would be the priority nursing diagnosis for a client with an ectopic pregnancy?
- A. Risk for infection
- B. Pain
- C. Knowledge Deficit
- D. Anticipatory Grieving
Correct answer: D
Rationale: Anticipatory grieving is the priority nursing diagnosis for a client with an ectopic pregnancy. An ectopic pregnancy is a life-threatening condition that requires immediate medical intervention, often resulting in emotional distress and potential loss. Anticipatory grieving addresses the emotional needs of the client and their family in anticipation of a possible loss. While pain management and infection prevention are important aspects of care, addressing the emotional well-being and coping mechanisms should take precedence in this situation. Knowledge deficit may also be relevant, but emotional support is crucial in this critical scenario.
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. The LPN/LVN is counseling a woman who wants to become pregnant. The woman tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. The nurse calculates that the woman's next fertile period is
- A. January 14-15.
- B. January 22-23.
- C. January 30-31.
- D. February 6-7.
Correct answer: C
Rationale: To determine the fertile period, subtract 14 days from the length of the woman's menstrual cycle. In this case, 36-14 = 22. Counting forward from the first day of the last menstrual period (January 8), the fertile period falls around January 30-31. This is because ovulation typically occurs approximately 14 days before the start of the next menstrual period, marking the fertile window for conception.