HESI LPN
HESI Mental Health Practice Exam
1. A male client with schizophrenia who is taking fluphenazine decanoate (Prolixin decanoate) is being discharged in the morning. A repeat dose of medication is scheduled for 20 days after discharge. The client tells the nurse that he is going on vacation in the Bahamas and will return in 18 days. Which statement by the client indicates a need for health teaching?
- A. "When I return from my tropical island vacation, I will go to the clinic to get my Prolixin injection."
- B. "While I am on vacation and when I return, I will not consume any alcohol-containing food or beverages."
- C. "I will inform the healthcare provider if I develop a sore throat or flu-like symptoms."
- D. "I will maintain my daily intake of benztropine mesylate (Cogentin)."
Correct answer: A
Rationale: Photosensitivity is a side effect of Prolixin, and a vacation in the Bahamas (with its tropical island climate) increases the client's risk of experiencing this side effect. Therefore, the client should be advised to avoid direct sun exposure. Choice A indicates a need for health teaching as the client plans to return from vacation in 18 days, which is earlier than the scheduled dose of Prolixin at 20 days after discharge. Choices B, C, and D demonstrate accurate knowledge. Choice B is important because alcohol can interact with Prolixin. Choice C is relevant as it mentions signs of agranulocytosis, a potential side effect of Prolixin. Choice D is correct as benztropine mesylate is used to prevent extrapyramidal symptoms associated with Prolixin.
2. The healthcare provider is assessing a client who has just undergone a thoracentesis. Which finding should be reported immediately?
- A. Diminished breath sounds on the affected side.
- B. Pain at the procedure site.
- C. Blood-tinged sputum.
- D. Shortness of breath.
Correct answer: D
Rationale: Shortness of breath should be reported immediately as it may indicate a pneumothorax, a potential complication of thoracentesis. Diminished breath sounds on the affected side, pain at the procedure site, and blood-tinged sputum are common findings post-thoracentesis and do not necessarily indicate immediate complications like a pneumothorax.
3. The nurse is caring for a 75-year-old client in congestive heart failure. Which finding suggests that digitalis levels should be reviewed?
- A. Extreme fatigue
- B. Increased appetite
- C. Intense itching
- D. Constipation
Correct answer: A
Rationale: Extreme fatigue can be a sign of digitalis toxicity, especially in older adults, and warrants a review of the client's medication levels and potential adjustment. Increased appetite, intense itching, and constipation are not typically associated with digitalis toxicity and do not directly indicate a need for a review of digitalis levels.
4. The debilitated patient is resisting attempts by the nurse to provide oral hygiene. Which action will the nurse take next?
- A. Insert an oral airway.
- B. Place the patient in a flat, supine position.
- C. Use undiluted hydrogen peroxide as a cleaner.
- D. Quickly proceed without talking to the patient.
Correct answer: A
Rationale: When a debilitated patient resists oral hygiene, the nurse should prioritize safety. Inserting an oral airway helps keep the mouth open, ensuring adequate access for oral care procedures while preventing any accidental biting or closure of the airway. Placing the patient in a flat, supine position may not address the resistance issue and can lead to aspiration risk. Using undiluted hydrogen peroxide is not recommended due to its potential harmful effects on oral tissues. Proceeding quickly without communication can escalate the situation and compromise patient-centered care.
5. The healthcare provider notes that a client has a new prescription for 20 mEq of potassium. The IV site is inflamed but not tender, and has a blood flashback. What action should the healthcare provider take?
- A. Obtain a liter of normal saline with 20 mEq of KCl
- B. Contact the healthcare provider to clarify the prescription
- C. Withhold the prescription medication until a new IV is started
- D. Fax the prescription to the pharmacy for immediate dispensing
Correct answer: B
Rationale: The healthcare provider should contact the prescriber to clarify the prescription because an inflamed IV site may indicate potential issues with administering the medication. It is important to ensure that the prescription is appropriate and safe for the client before proceeding with administration. Option A is incorrect because administering potassium through an inflamed IV site can lead to further complications. Option C is not the best course of action as clarifying the prescription first is essential. Option D is also incorrect as the focus should be on ensuring the safety of the client before dispensing the medication.