HESI RN
Quizlet Mental Health HESI
1. A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit’s day room. What action should the nurse implement first?
- A. Administer a PRN sedative.
- B. Sit in the chair next to the client.
- C. Escort the client to his room.
- D. Listen to what the client is saying.
Correct answer: D
Rationale: When dealing with a client experiencing auditory hallucinations, it is crucial for the nurse to first listen to what the client is saying. Auditory hallucinations may hold significance to the client, and by actively listening, the nurse can gather information about the content and context of the hallucinations. This information helps the nurse assess the client's current state, emotional responses, and the potential triggers for the behavior. Administering a PRN sedative (Choice A) should not be the initial action as it may suppress important information and feelings the client is trying to communicate. Sitting next to the client (Choice B) may not be appropriate without understanding the situation better. Escorting the client to his room (Choice C) may escalate the situation without addressing the underlying cause of the behavior, which can be better understood through active listening.
2. An obese client with emphysema who smoked at least a pack of cigarettes daily is admitted after experiencing a sudden increase in dyspnea and activity intolerance. Oxygen therapy is initiated, and it is determined that the client will be discharged with oxygen. Which information is most important for the nurse to emphasize in the discharge teaching plan?
- A. Methods for weight loss
- B. Guidelines for oxygen use
- C. Approaches to conserve energy
- D. Strategies for smoking cessation
Correct answer: B
Rationale: In this scenario, the priority for the nurse to emphasize in the discharge teaching plan is the 'Guidelines for oxygen use.' As the client with emphysema is being discharged with oxygen therapy, it is crucial for the nurse to ensure that the client understands how to use oxygen properly to prevent complications and promote effective management of the condition. While weight loss, conserving energy, and smoking cessation are important aspects of care for this client, in this specific case, ensuring the safe and appropriate use of supplemental oxygen takes precedence to optimize the client's respiratory function and overall well-being.
3. Which serum laboratory value should the nurse monitor carefully for a client who has had an NG tube for suctioning for the past week?
- A. White blood cell count
- B. Albumin
- C. Calcium
- D. Sodium
Correct answer: D
Rationale: The nurse should carefully monitor serum sodium levels for a client with an NG tube on suction for an extended period due to potential fluid loss and the risk of developing hyponatremia, an electrolyte imbalance. Hyponatremia can occur as a result of continual suctioning leading to fluid loss, making it crucial to monitor sodium levels to prevent complications associated with low sodium levels. Monitoring white blood cell count, albumin, or calcium is not directly related to the impact of NG tube suction on fluid and electrolyte balance, so these values are not the priority in this scenario.
4. The healthcare provider is caring for a client with Cushing's syndrome. Which of the following nursing interventions is appropriate?
- A. Monitor blood glucose levels
- B. Restrict fluid intake
- C. Administer potassium supplements
- D. Encourage a high-protein diet
Correct answer: A
Rationale: Clients with Cushing's syndrome are at risk for hyperglycemia due to the effects of cortisol on glucose metabolism. Monitoring blood glucose levels is crucial to detect and manage hyperglycemia promptly. Restricting fluid intake (choice B) is not necessary unless specifically indicated for another condition, as clients with Cushing's syndrome are prone to fluid imbalances. Administering potassium supplements (choice C) is not appropriate as clients with Cushing's syndrome often have elevated potassium levels due to the effects of cortisol. Encouraging a high-protein diet (choice D) is not recommended as clients with Cushing's syndrome should focus on a balanced diet to manage their condition effectively.
5. A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Which finding requires immediate intervention?
- A. Oxygen saturation of 88%
- B. Respiratory rate of 24 breaths per minute
- C. Heart rate of 90 beats per minute
- D. Productive cough with green sputum
Correct answer: D
Rationale: In a client with COPD admitted with pneumonia, a productive cough with green sputum indicates a potential bacterial infection. Green sputum is commonly associated with bacterial pneumonia, which requires immediate intervention with appropriate antibiotics. Monitoring oxygen saturation, respiratory rate, and heart rate are essential in COPD patients, but the presence of green sputum suggests an urgent need for targeted treatment to address the underlying infection. Oxygen saturation of 88% is concerning but may not directly indicate the need for immediate intervention in the absence of other critical symptoms. Respiratory rate of 24 breaths per minute and a heart rate of 90 beats per minute are within normal limits and may not be indicative of an acute issue requiring immediate intervention in this context.