HESI RN
Quizlet Mental Health HESI
1. What should the nurse initially assess when a high school girl reveals engaging in self-induced vomiting as a weight-control measure?
- A. National percentile of weight and height.
- B. Frequency of bingeing and purging behaviors.
- C. Perceptions of family and social relationships.
- D. School grades and extracurricular activities.
Correct answer: B
Rationale: The correct answer is assessing the frequency of bingeing and purging behaviors. This assessment is crucial in understanding the severity of the eating disorder and developing an appropriate treatment plan. Options A, C, and D are not the initial priority when dealing with a student engaging in harmful behaviors related to eating disorders. While weight and height, family relationships, and academic performance are important aspects to consider, the immediate focus should be on evaluating the behaviors directly linked to the reported issue.
2. A client who had a subtotal parathyroidectomy two days ago is now preparing for discharge. Which assessment finding requires immediate provider notification?
- A. Afebrile with a normal pulse.
- B. No bowel movement since surgery.
- C. No appetite for breakfast.
- D. A positive Chvostek's sign.
Correct answer: D
Rationale: A positive Chvostek's sign suggests hypocalcemia, which is a post-parathyroidectomy complication and requires prompt treatment. The other options are less urgent: being afebrile with a normal pulse is expected, no bowel movement since surgery can be managed with interventions like early ambulation and stool softeners, and no appetite for breakfast is common postoperatively and can be addressed without immediate provider notification.
3. The nurse is assessing a client with a small bowel obstruction who was hospitalized 24 hours ago. Which assessment finding should the nurse report immediately to the healthcare provider?
- A. Hypoactive bowel sounds in the lower quadrant.
- B. Rebound tenderness in the upper quadrants.
- C. Tympany with percussion of the abdomen.
- D. Light-colored gastric aspirate via the nasogastric tube.
Correct answer: B
Rationale: Rebound tenderness in the upper quadrants may indicate peritonitis, which requires prompt medical attention. Hypoactive bowel sounds are expected in small bowel obstruction and would not be a priority over signs of peritonitis. Tympany with percussion is a normal finding and not a cause for immediate concern. Light-colored gastric aspirate could indicate various issues but is not as urgent as peritonitis.
4. A client is being educated by a healthcare professional about initiating a prescribed abstinence therapy using Disulfiram (Antabuse). What information should the client acknowledge understanding?
- A. Admit to others that they are a substance abuser.
- B. Remain alcohol-free for 12 hours before taking the first dose.
- C. Attend monthly Alcoholics Anonymous meetings.
- D. Completely abstain from heroin or cocaine use.
Correct answer: B
Rationale: B: Before starting Disulfiram therapy, it is crucial for clients to be alcohol-free for a minimum of 12 hours to prevent adverse reactions. A: Admitting substance abuse is important, but it is not directly linked to the initiation of Disulfiram therapy. C: Attending Alcoholics Anonymous meetings is beneficial for support but not a specific requirement for starting Disulfiram. D: The focus of Disulfiram therapy is on alcohol abstinence, so abstaining from heroin or cocaine is not directly related to this medication.
5. A female client is brought to the clinic by her daughter for a flu shot. She has lost significant weight since the last visit. She has poor personal hygiene and inadequate clothing for the weather. The client states that she lives alone and denies problems or concerns. What action should the nurse implement?
- A. Notify social services immediately if suspected elderly abuse is present.
- B. Discuss the need for mental health counseling with the daughter.
- C. Explain to the client the importance of taking better care of herself.
- D. Collect further data to determine whether self-neglect is occurring.
Correct answer: D
Rationale: In this scenario, the client presents with significant weight loss, poor hygiene, and inadequate clothing, which are concerning signs of self-neglect. Before taking action, it is crucial for the nurse to collect more data to determine the root cause of these issues. Jumping to conclusions or immediately involving social services without a thorough assessment could potentially harm the client or strain relationships. Discussing the need for mental health counseling with the daughter or simply advising the client to take better care of herself may not address the underlying problem of self-neglect. Therefore, the most appropriate initial action is for the nurse to collect further data to make an informed decision before taking the next steps.