HESI RN
Quizlet HESI Mental Health
1. A female client with obsessive-compulsive personality disorder is admitted to the hospital for a cardiac catheterization. The afternoon before the procedure, the client begins to keep detailed notes of the nursing care she is receiving and reports her findings to the RN at bedtime. What action should the nurse implement?
- A. Explain to the client that her behavior invades the rights of the nursing staff.
- B. Ask the client to explain why she is keeping a detailed record of her nursing care.
- C. Teach the client strategies to control her obsessive-compulsive behavior.
- D. Encourage the client to express her feelings regarding the upcoming procedure.
Correct answer: B
Rationale: Asking the client to explain why she is keeping a detailed record of her nursing care is the most appropriate action for the nurse to take in this situation. Understanding the client’s motivations for keeping detailed records can provide insight into her obsessive-compulsive behaviors and help manage them effectively. This approach allows for a non-confrontational exploration of the behavior. Choice A is incorrect because it may be perceived as confrontational and does not address the underlying reasons for the behavior. Choice C is incorrect because teaching strategies to control behavior should come after understanding the client's motives. Choice D is incorrect as it does not directly address the behavior of keeping detailed records, which is the immediate concern that needs to be addressed.
2. An adult client who received partial thickness burns on 40% of the body in a house fire is admitted to the inpatient burn unit. Which fluid should the nurse prepare to administer during the client's burn recovery?
- A. 5% dextrose in water
- B. 5% dextrose in 0.25 normal saline
- C. Total parenteral nutrition
- D. Lactated Ringer's
Correct answer: D
Rationale: During the burn recovery phase, the nurse should prepare to administer Lactated Ringer's solution. Lactated Ringer's is the preferred fluid choice for burn patients as it helps replace lost fluids and electrolytes, maintain perfusion, and support organ function. Option A, 5% dextrose in water, is not the appropriate choice for fluid resuscitation in burn patients. Option B, 5% dextrose in 0.25 normal saline, does not provide the necessary electrolytes needed for burn recovery. Option C, Total parenteral nutrition, may be considered later in the treatment but is not the initial fluid of choice for burn recovery.
3. A client is receiving furosemide (Lasix) and is being discharged. What should the nurse include in the teaching plan?
- A. Consume potassium-rich foods.
- B. Take the medication in the morning.
- C. Change positions slowly to prevent dizziness.
- D. Maintain an adequate fluid intake.
Correct answer: C
Rationale: The correct answer is to instruct the client to change positions slowly to prevent dizziness. Furosemide (Lasix) is a diuretic that can lead to orthostatic hypotension, causing dizziness. Consuming potassium-rich foods is essential to prevent hypokalemia when taking furosemide. Taking the medication in the morning helps reduce the need for frequent urination at night. Encouraging the client to maintain an adequate fluid intake is crucial to prevent dehydration while on this medication.
4. During which stage of mitosis do the chromosomes gather on either side of the separating cell?
- A. Metaphase
- B. Telophase
- C. Anaphase
- D. Prophase
Correct answer: B
Rationale: The correct answer is B, Telophase. During telophase, the chromosomes gather at opposite poles of the cell as the nuclear envelopes start to form around them, indicating the end of cell division. Choices A, C, and D are incorrect because during metaphase, the chromosomes align in the middle of the cell; in anaphase, the chromosomes separate and move towards opposite poles; and in prophase, the chromosomes condense and the nuclear envelope breaks down, respectively.
5. The nurse on the day shift receives report about a client with depression who was found on the floor in the morning. What intervention is best for the nurse to implement?
- A. Assist the client to get out of bed and involved in an activity.
- B. Monitor the client’s appetite and sleep patterns.
- C. Assess the client’s feelings regarding the hospital stay.
- D. Explain that staff will check on the client every 30 minutes.
Correct answer: A
Rationale: Assisting the client to engage in activities is the best intervention as it can help improve mood and prevent further decline in function. This intervention can also help the client regain a sense of control and purpose. Option B, monitoring appetite and sleep patterns, is important but not the most immediate intervention needed in this situation. Option C, assessing feelings about the hospital stay, is also important but addressing the client's physical safety and well-being should take precedence. Option D, explaining the frequency of staff checks, is not as effective in addressing the client's immediate needs for engagement and support.