HESI RN
Mental Health HESI Quizlet
1. A male client approaches the nurse with an angry expression on his face and raises his voice, saying, “My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out!” The nurse recognizes that the client is using which defense mechanism?
- A. Denial
- B. Projection
- C. Rationalization
- D. Splitting
Correct answer: B
Rationale: The correct answer is B: Projection. In this scenario, the client is projecting his own feelings of anger onto his roommate by attributing his anger to the roommate. Projection involves shifting one's feelings, thoughts, or impulses onto another person. Denial (choice A) is the refusal to accept reality, Rationalization (choice C) involves justifying behaviors with logical reasons, and Splitting (choice D) is the inability to integrate positive and negative qualities of oneself or others.
2. A client with chronic renal failure is being treated with sodium polystyrene sulfonate (Kayexalate). The nurse should monitor the client for which of the following?
- A. Hyponatremia.
- B. Hypokalemia.
- C. Hyperkalemia.
- D. Hypocalcemia.
Correct answer: C
Rationale: The correct answer is C: Hyperkalemia. Sodium polystyrene sulfonate (Kayexalate) is used to treat high potassium levels (hyperkalemia) by exchanging sodium ions for potassium ions in the large intestine, which is then eliminated through the feces. Therefore, the nurse should monitor the client for changes in potassium levels to ensure the effectiveness of the treatment. Choices A, B, and D are incorrect because sodium polystyrene sulfonate (Kayexalate) is not associated with causing hyponatremia, hypokalemia, or hypocalcemia.
3. A client with elevated levels of antidiuretic hormone (ADH) triggers the release of this hormone due to which disorder?
- A. Pneumonia
- B. Dehydration
- C. Renal failure
- D. Edema
Correct answer: B
Rationale: Antidiuretic hormone (ADH) increases tubular permeability to water, causing more water absorption into the capillaries. ADH is released in response to a rising extracellular fluid osmolarity, such as in dehydration. Pneumonia, renal failure, and edema do not typically lead to the release of ADH. Pneumonia is an inflammatory lung condition, renal failure affects kidney function, and edema is the accumulation of excess fluid in the tissues, none of which directly stimulate the release of ADH.
4. Which structure maintains the uterus in an anteverted and anteflexed position?
- A. Round ligaments
- B. Broad ligaments
- C. Cardinal ligaments
- D. Pubocervical ligaments
Correct answer: A
Rationale: The correct answer is the Round ligaments. The round ligaments are responsible for maintaining the uterus in an anteverted and anteflexed position. These ligaments attach from the sides of the uterus and extend through the inguinal canal to the labia majora. The other choices, Broad ligaments, Cardinal ligaments, and Pubocervical ligaments, have different functions and attachments within the pelvis. Broad ligaments are a double layer of peritoneum that encloses the uterus and supports the uterine tubes. Cardinal ligaments provide support to the cervix and upper vagina. Pubocervical ligaments support the cervix and bladder.
5. When reinforcing teaching with the parents of a 7-year-old child with attention-deficit/hyperactivity disorder (ADHD) about the child's medication, which statement by the parents indicates an understanding of the medication's side effects?
- A. We should monitor our child's growth and appetite regularly.
- B. The medication may cause drowsiness, so we will give it at bedtime.
- C. We need to give the medication with food to avoid stomach upset.
- D. The medication can cause increased urination, so fluid intake should be limited.
Correct answer: A
Rationale: The correct answer is A: 'We should monitor our child's growth and appetite regularly.' Correct monitoring of the child's growth and appetite is crucial when a child is on ADHD medications, especially stimulants, as these medications can have side effects related to growth and appetite. Monitoring these parameters regularly helps in assessing the medication's impact and making any necessary adjustments. Choices B, C, and D are incorrect: B talks about drowsiness, C mentions avoiding stomach upset, and D refers to increased urination and limiting fluid intake. While these are potential side effects of medications, they do not directly address the importance of monitoring growth and appetite, which is crucial in children on ADHD medications.