HESI RN
Quizlet Mental Health HESI
1. A male client who recently lost a loved one arrives at the mental health center and tells the nurse he is no longer interested in his usual activities and has not slept for several days. Which priority nursing problem should the nurse include in this client’s plan of care?
- A. Risk for suicide
- B. Sleep deprivation
- C. Situational low self-esteem
- D. Social isolation
Correct answer: A
Rationale: The correct answer is A: Risk for suicide. Considering the client's recent loss, lack of interest in activities, and sleep disturbances, the nurse should prioritize assessing and addressing the risk for suicide. This client is displaying warning signs such as loss of interest in usual activities and sleep disturbances, which are commonly associated with suicidal ideation. B: Sleep deprivation is not the priority issue in this scenario, as the client's lack of sleep is likely a symptom of a deeper emotional struggle. C: Situational low self-esteem and D: Social isolation may be concerns for this client but do not take precedence over the immediate risk of suicide, given the presented symptoms.
2. A client with hypertension receives a prescription for enalapril, an angiotensin-converting enzyme (ACE) inhibitor. Which instruction should the nurse include in the medication teaching plan?
- A. Increase intake of potassium-rich foods.
- B. Report increased bruising or bleeding.
- C. Stop medication if a cough develops.
- D. Limit intake of leafy green vegetables.
Correct answer: B
Rationale: The correct instruction for the nurse to include in the medication teaching plan is to 'Report increased bruising or bleeding.' ACE inhibitors can cause thrombocytopenia, which lowers platelet count and increases the risk of bruising and bleeding. Choice A is incorrect because while ACE inhibitors may cause potassium levels to increase, the instruction should not be to increase intake of potassium-rich foods without healthcare provider guidance. Choice C is incorrect because a cough is a common side effect of ACE inhibitors due to bradykinin accumulation, and stopping the medication abruptly is not recommended without consulting the healthcare provider. Choice D is incorrect because there is no need to limit intake of leafy green vegetables specifically with ACE inhibitors; however, consistent intake of vitamin K-rich foods is recommended to maintain a stable INR for clients taking anticoagulants.
3. Following a lumbar puncture, a client voices several complaints. What complaint indicates to the nurse that the client is experiencing a complication?
- A. I am having pain in my lower back when I move my legs
- B. My throat hurts when I swallow
- C. I feel sick to my stomach and am going to throw up
- D. I have a headache that gets worse when I sit up
Correct answer: D
Rationale: The correct answer is D. A post-lumbar puncture headache, ranging from mild to severe, may occur as a result of leakage of cerebrospinal fluid at the puncture site. This complication is usually managed by bed rest, analgesics, and hydration. Choices A, B, and C do not directly indicate complications associated with a lumbar puncture. Pain in the lower back when moving legs, a sore throat when swallowing, and nausea with a feeling of vomiting are not typical complications of lumbar puncture.
4. What is the most important instruction for the nurse to provide a client being discharged following treatment for Guillain-Barre syndrome?
- A. Avoid exposure to respiratory infections.
- B. Use relaxation exercises when anxious.
- C. Continue physical therapy at home.
- D. Plan short, frequent rest periods.
Correct answer: A
Rationale: The most critical instruction for a client being discharged following treatment for Guillain-Barre syndrome is to avoid exposure to respiratory infections. Guillain-Barre syndrome can affect the respiratory system, making infections particularly dangerous. While relaxation exercises, physical therapy, and rest periods are beneficial for overall well-being and recovery, preventing respiratory infections takes precedence due to the potential life-threatening complications associated with respiratory compromise in Guillain-Barre syndrome.
5. An overweight client taking warfarin (Coumadin) has dry skin due to decreased arterial blood flow. What should the nurse instruct the client to do? Select all that apply.
- A. Apply lanolin or petroleum jelly to intact skin.
- B. Follow a reduced-calorie, reduced-fat diet.
- C. Inspect the involved areas daily for new ulcerations.
- D. Instruct the client to limit activities of daily living (ADLs).
Correct answer: A
Rationale: To address dry skin and prevent chronic ulcers and infections in an overweight client on warfarin with decreased arterial blood flow, the nurse should instruct the client to apply lanolin or petroleum jelly to intact skin. This helps maintain skin integrity and moisture. Following a reduced-calorie, reduced-fat diet (Choice B) may be beneficial for weight management but is not directly related to skin care. Inspecting involved areas daily for new ulcerations (Choice C) is important for skin assessment and early intervention but does not specifically address dry skin. Instructing the client to limit activities of daily living (ADLs) (Choice D) is not necessary for addressing dry skin; in fact, promoting mobility and circulation through appropriate activities is crucial.