HESI RN
Mental Health HESI
1. A male client with bipolar disorder tells the nurse that he needs to 'make some deals so that he can improve his retirement savings.' Based on this information, which client outcome should the nurse include in the plan of care?
- A. Delay business decisions until his mania subsides.
- B. Identify the feelings associated with his behaviors.
- C. Seek legal counsel when making business decisions.
- D. Describe why he is feeling fearful about his finances.
Correct answer: A
Rationale: In individuals with bipolar disorder experiencing mania, impulsivity and poor judgment are common. Delaying business decisions until the mania subsides is crucial to prevent impulsive and potentially harmful financial choices. Choice B, identifying feelings associated with behaviors, may be important but does not directly address the immediate need to prevent risky financial decisions. Seeking legal counsel (Choice C) may be appropriate in some situations but is not the priority in managing acute mania. Describing why he feels fearful about finances (Choice D) is relevant for understanding emotions but does not address the immediate risk of impulsive financial actions during mania.
2. Prior to administering warfarin to a client with a history of atrial fibrillation, what lab result should the nurse review?
- A. White blood cell count.
- B. Prothrombin time (PT) and International Normalized Ratio (INR).
- C. Hemoglobin and hematocrit.
- D. Blood urea nitrogen (BUN) and creatinine.
Correct answer: B
Rationale: The correct answer is B: Prothrombin time (PT) and International Normalized Ratio (INR). These lab values are crucial for monitoring the effectiveness of warfarin, an anticoagulant medication. PT measures the time it takes for blood to clot, while INR standardizes these results. Ensuring the client's PT/INR levels are within the therapeutic range is essential to prevent clotting or excessive bleeding. Choices A, C, and D are incorrect as they are not directly related to monitoring warfarin therapy in a client with atrial fibrillation.
3. A client with a history of chronic kidney disease (CKD) is admitted with hyperkalemia. Which clinical finding is most concerning?
- A. Peaked T waves on the ECG
- B. Bradycardia
- C. Muscle weakness
- D. Decreased deep tendon reflexes
Correct answer: A
Rationale: Peaked T waves on the ECG are the most concerning finding in a client with hyperkalemia. Hyperkalemia can lead to serious cardiac complications, including arrhythmias and cardiac arrest. Peaked T waves are a classic ECG finding associated with hyperkalemia and indicate the need for immediate intervention. Bradycardia, muscle weakness, and decreased deep tendon reflexes can also be seen in hyperkalemia, but the presence of peaked T waves signifies a higher risk of cardiac events, making it the most concerning finding in this scenario.
4. A pregnant client receives Rho(D) immune globulin after an amniocentesis. The day following, she reports a temperature of 99.8°F (37.67°C). Which action should the nurse implement?
- A. Schedule a visit with the healthcare provider today.
- B. Verify the compatibility of the administered Rho(D) immune globulin.
- C. Encourage the client to increase her intake of oral fluids.
- D. Instruct the client to maintain bedrest for 24 hours.
Correct answer: C
Rationale: A mild increase in temperature post-amniocentesis is common, and encouraging the client to increase oral fluid intake is the appropriate action. Increasing fluid intake can help reduce mild fever, promote recovery, and prevent dehydration. It is important for the nurse to educate the client on the importance of staying hydrated to support her overall well-being during this time.
5. A client with a colostomy is being discharged. What teaching is most important for the nurse to provide?
- A. Change the ostomy bag daily to prevent skin irritation.
- B. Avoid foods that can cause gas, such as broccoli.
- C. Empty the ostomy pouch when it is one-third full.
- D. Use a skin barrier to protect the surrounding skin.
Correct answer: C
Rationale: The most important teaching for a client with a colostomy is to empty the ostomy pouch when it is one-third full. This practice helps prevent leakage and skin irritation by maintaining the proper seal of the pouching system. Changing the ostomy bag daily (Choice A) is not necessary unless it leaks or becomes loose. Avoiding gas-producing foods (Choice B) is essential for some clients but is not the most important teaching. Using a skin barrier (Choice D) is important but not as crucial as emptying the ostomy pouch at the right time to prevent complications.