HESI LPN
HESI Mental Health 2023
1. A nurse is assessing a client with generalized anxiety disorder (GAD) who reports difficulty concentrating and feeling restless. What is the most appropriate nursing intervention?
- A. Encourage the client to avoid caffeine.
- B. Suggest the client take up a new hobby.
- C. Teach the client deep breathing exercises.
- D. Refer the client to group therapy.
Correct answer: C
Rationale: Teaching deep breathing exercises is the most appropriate intervention for a client with generalized anxiety disorder (GAD) experiencing difficulty concentrating and restlessness. Deep breathing exercises are a proven technique to help manage anxiety symptoms, promote relaxation, and improve concentration. Encouraging the client to avoid caffeine (Choice A) may be beneficial, but it is not the most direct intervention for the reported symptoms. Suggesting the client take up a new hobby (Choice B) may be helpful for overall well-being but does not directly address the immediate symptoms. Referring the client to group therapy (Choice D) may be beneficial in the long term, but teaching deep breathing exercises is more immediate and can be easily implemented by the client in various settings.
2. The nurse is reviewing the laboratory test results of a child diagnosed with disseminated intravascular coagulation (DIC). What would the nurse interpret as indicative of this disorder?
- A. Shortened prothrombin time
- B. Increased fibrinogen level
- C. Positive fibrin split products
- D. Increased platelets
Correct answer: C
Rationale: Positive fibrin split products are indicative of disseminated intravascular coagulation (DIC). In DIC, there is widespread clotting and subsequent consumption of clotting factors, leading to the formation of fibrin split products. A shortened prothrombin time (Choice A) is not typically seen in DIC as it indicates faster clotting, which is opposite to the pathophysiology of DIC. An increased fibrinogen level (Choice B) may be observed in the early stages of DIC due to the compensatory increase in production, but it is not a definitive indicator. Increased platelets (Choice D) may be seen in the early stages of DIC due to the body's attempt to compensate for clot formation, but it is not a specific finding for DIC.
3. The parents of a child who has just been diagnosed with type 1 diabetes ask about exercise. What should the nurse explain about exercise in type 1 diabetes?
- A. Exercise will increase blood glucose levels
- B. Exercise should be restricted
- C. Extra snacks are needed before exercise
- D. Extra insulin is required during exercise
Correct answer: C
Rationale: In type 1 diabetes, extra snacks are needed before exercise to prevent hypoglycemia. It is important to provide additional carbohydrates to maintain blood glucose levels during physical activity. Choices A, B, and D are incorrect. Exercise typically lowers blood glucose levels in individuals with diabetes; however, proper management and adjustments in insulin and food intake are necessary to prevent hypoglycemia. Exercise should not be restricted in individuals with type 1 diabetes but should be planned in coordination with healthcare providers to ensure safety and optimal glucose control. While some individuals may need adjustments in insulin dosages during exercise, the general statement that extra insulin is required during exercise in type 1 diabetes is not accurate.
4. A male client receives a scopolamine transdermal patch 2 hours before surgery. Four hours after surgery, the client tells the nurse that he is experiencing pain and asks why the patch is not working. Which action should the nurse take?
- A. Advise the client that the effects of the medication have worn off
- B. Explain that the medication is not given to relieve pain
- C. Check for the correct placement of the patch on the client
- D. Offer to apply a new transdermal patch to address the pain
Correct answer: B
Rationale: The correct answer is B. Scopolamine is not a pain medication; it is commonly used to prevent nausea and vomiting, particularly in surgical settings. It works on the central nervous system to help control these symptoms, not to relieve pain. Therefore, it is important for the nurse to explain to the client that the medication is not intended to relieve pain but rather to manage other specific symptoms. Checking the correct placement of the patch is also important to ensure proper administration, but addressing the misconception about the medication's purpose is the priority in this scenario. Offering to apply a new patch would not address the client's pain as scopolamine is not meant for pain relief. Advising the client that the effects have worn off is inaccurate because the medication is not used for pain management.
5. A client has active genital herpes simplex virus type 2. Which of the following medications should the nurse plan to administer?
- A. Metronidazole
- B. Penicillin
- C. Acyclovir
- D. Gentamicin
Correct answer: C
Rationale: Acyclovir is the antiviral medication specifically used to treat herpes simplex virus infections, including genital herpes caused by herpes simplex virus type 2. Metronidazole (Choice A) is an antibiotic used for different types of infections, but not for viral infections like herpes. Penicillin (Choice B) is an antibiotic effective against bacterial infections, not viruses like herpes. Gentamicin (Choice D) is an antibiotic mainly used to treat bacterial infections, not viral infections like herpes.