HESI LPN
HESI Mental Health
1. A male client is admitted to the psychiatric unit with a medical diagnosis of paranoid schizophrenia. During the admission procedure, the client looks up and states, 'No, it's not MY fault. You can't blame me. I didn't kill him, you did.' What action is best for the nurse to take?
- A. Reassure the client by telling him that his fear of the admission procedure is to be expected.
- B. Tell the client that no one is accusing him of murder and remind him that the hospital is a safe place.
- C. Assess the content of the hallucinations by asking the client what he is hearing.
- D. Ignore the behavior and make no response at all to his delusional statements.
Correct answer: C
Rationale: The correct action for the nurse to take in this situation is to assess the content of the hallucinations by asking the client what he is hearing (C). Further assessment is needed to understand the nature of the client's delusions and hallucinations. Choice A is incorrect as it focuses on reassuring the client about his fear, which is not addressing the underlying issue of the delusional statement. Choice B is incorrect as it argues with the client's delusion and offers false reassurance, which is not therapeutic. Choice D is incorrect as ignoring the behavior and making no response disregards the client's needs for assessment and support.
2. The mother of a breastfeeding 24-hour old infant is very concerned about the techniques involved in breastfeeding. She calls the nurse with each feeding to seek reassurance that she is doing it right. She tells the nurse, "Now my daughter is not getting enough to eat." Which response would be best for the nurse to make?
- A. Feed your baby hourly until you feel confident that your child is receiving enough milk.
- B. Don't worry, soon your milk will come in, and you will feel how full your breasts are.
- C. Since you are so concerned, you should probably supplement breastfeeding with formula.
- D. If your baby's urine is straw-colored, she's getting enough milk.
Correct answer: D
Rationale: Reassuring the mother that the baby's urine color can be an indicator of adequate hydration can help her feel more confident in her breastfeeding.
3. A client with a diagnosis of bipolar disorder is prescribed topiramate. The nurse should monitor for which potential adverse effect?
- A. Cognitive impairment
- B. Weight gain
- C. Liver toxicity
- D. Weight loss
Correct answer: A
Rationale: Correct. Topiramate is associated with cognitive impairment as an adverse effect. It is important for the nurse to monitor the client's cognitive function while on this medication to assess for any signs of cognitive decline or impairment. Choice B, weight gain, is incorrect as topiramate is actually associated with weight loss rather than weight gain. Choice C, liver toxicity, is also incorrect as topiramate is not known to cause liver toxicity. Choice D, weight loss, is not the correct answer as topiramate is not associated with weight gain.
4. A 16-year-old enters the emergency department. The triage nurse identifies that this teenager is legally married and signs the consent form for treatment. What would be the appropriate action by the nurse?
- A. Ask the teenager to wait until a parent or legal guardian can be contacted
- B. Withhold treatment until telephone consent can be obtained from the partner
- C. Refer the teenager to a community pediatric hospital emergency department
- D. Proceed with the triage process in the same manner as any adult client
Correct answer: D
Rationale: The correct answer is to proceed with the triage process in the same manner as any adult client. In this scenario, since the teenager is legally married, they have the legal authority to consent to their own treatment. Choice A is incorrect because the teenager, being legally married, can provide their own consent. Choice B is incorrect as it unnecessarily delays treatment by waiting for telephone consent from the partner, which is not required in this case. Choice C is incorrect as the teenager can receive appropriate care in the current emergency department setting without the need for referral.
5. A client with a peripherally inserted central catheter (PICC) line has a fever. What client assessment is most important for the nurse to perform?
- A. Observe the PICC line site for inflammation.
- B. Encourage increasing fluid intake.
- C. Monitor blood pressure regularly.
- D. Assess skin turgor for dehydration.
Correct answer: A
Rationale: The correct answer is to observe the PICC line site for inflammation. When a client with a PICC line develops a fever, it could indicate an infection related to the catheter. Assessing the PICC line site for signs of inflammation, such as redness, warmth, swelling, or drainage, is crucial in identifying a potential infection early. Choice B is incorrect because increasing fluid intake is not directly related to assessing a PICC line for infection. Choice C is not the most appropriate assessment in this situation as monitoring blood pressure may not directly help in identifying the cause of the fever. Choice D is unrelated to the assessment of a fever in a client with a PICC line.