HESI RN
Quizlet Mental Health HESI
1. A middle-aged female client with no previous psychiatric history is seen in the mental health clinic because her family describes her as having paranoid thoughts. On assessment, she tells the nurse, “I want to find out why these people are stalking me.” Which response should the nurse provide?
- A. It sounds like this experience is frightening for you.
- B. What makes you think people are stalking you?
- C. I know you are frightened, but no one is stalking you.
- D. Do you think someone is trying to harm you?
Correct answer: A
Rationale: The correct response for the nurse to provide is option A: 'It sounds like this experience is frightening for you.' This response acknowledges the client's feelings and emotions without directly challenging the delusion of being stalked. Option B is incorrect as it directly questions the client's belief, which can lead to increased defensiveness. Option C is incorrect as it denies the client's belief without addressing the underlying fear and can cause the client to feel misunderstood. Option D is incorrect as it directly asks about harm, which may not be the primary concern of the client at this moment.
2. A nurse is providing instructions to an adolescent who has a history of seizures and is taking an anticonvulsant medication. Which of the following statements indicates that the client understands the instructions?
- A. I will never be able to drive a car.
- B. My anticonvulsant medication will clear up my skin.
- C. I can't drink alcohol while I am taking my medication.
- D. If I forget my morning medication, I can take two pills at bedtime.
Correct answer: C
Rationale: The correct answer is C: 'I can't drink alcohol while I am taking my medication.' Alcohol can lower the seizure threshold and should be avoided by individuals taking anticonvulsants. Choice A is incorrect because it is an extreme statement and not necessary for someone taking anticonvulsants. Choice B is incorrect as anticonvulsant medications are not used to clear skin conditions. Choice D is incorrect because doubling up medication doses can be harmful and should not be done without healthcare provider approval.
3. What is Dinoprostone commonly used for?
- A. Cervical priming.
- B. Pain management during labor.
- C. Management of pre-term labor.
- D. Management of post-partum hemorrhage.
Correct answer: C
Rationale: Dinoprostone is commonly used for the management of pre-term labor. While it can be used for cervical priming, its primary indication is for pre-term labor. Choice A is partially correct but not the most common use of Dinoprostone. Choices B and D are incorrect as Dinoprostone is not primarily used for pain management during labor or for the management of post-partum hemorrhage.
4. After checking the client’s gag reflex following an esophagogastroduodenoscopy (EGD), which action should the nurse take?
- A. Taking the client’s vital signs
- B. Giving the client a drink of water
- C. Monitoring the client for a sore throat
- D. Being alert to complaints of heartburn
Correct answer: A
Rationale: After an esophagogastroduodenoscopy (EGD), the nurse's priority is to assess the client's airway by checking the gag reflex. Once this assessment is done, the next step is to take the client's vital signs to monitor for any signs of complications such as bleeding or changes in respiratory status. Giving the client water immediately after the procedure may not be appropriate, as the client may still have a compromised gag reflex and is at risk for aspiration. Monitoring for a sore throat is important but not the immediate priority post-procedure. Being alert to complaints of heartburn is relevant for assessing the client's symptoms but is not the priority immediately after checking the gag reflex.
5. A client who is mouth breathing is receiving oxygen by face mask. The nursing assistant asks the nurse why a water bottle is attached to the oxygen tubing near the wall oxygen outlet. The nurse responds that the primary purpose of the water is to:
- A. Prevent the client from getting a nosebleed
- B. Give the client added fluid by way of the respiratory tree
- C. Humidify the oxygen that is bypassing the client’s nose
- D. Prevent fluid loss from the lungs during mouth breathing
Correct answer: C
Rationale: The purpose of the water bottle is to humidify the oxygen that is bypassing the nose during mouth breathing. When a client breathes through the mouth, the oxygen delivered by the face mask bypasses the natural humidification provided by the nasal passages. Therefore, the water bottle attachment helps to add moisture to the oxygen, preventing dryness and irritation to the respiratory tract. Choices A, B, and D are incorrect. Clients breathing through the mouth are not at risk for nosebleeds, do not receive added fluid through the respiratory tree, and do not experience fluid loss from the lungs due to mouth breathing.