HESI LPN
Mental Health HESI 2023
1. A client with depression reports difficulty sleeping. What is the most appropriate nursing intervention?
- A. Encourage the client to take short naps during the day.
- B. Suggest the client drink a warm beverage before bedtime.
- C. Recommend the client exercise immediately before bedtime.
- D. Advise the client to take a sleep aid nightly.
Correct answer: B
Rationale: The most appropriate nursing intervention for a client with depression reporting difficulty sleeping is to suggest the client drink a warm beverage before bedtime. A warm beverage can promote relaxation and help establish a bedtime routine, which may aid in improving sleep quality. Encouraging short naps during the day (Choice A) may disrupt the client's nighttime sleep pattern. Recommending exercise immediately before bedtime (Choice C) can have a stimulating effect, making it harder for the client to fall asleep. Advising the client to take a sleep aid nightly (Choice D) should only be considered after other non-pharmacological interventions have been attempted and in consultation with a healthcare provider due to potential side effects and risks associated with sleep aids.
2. A client has just returned to the medical-surgical unit following a segmental lung resection. After assessing the client, the first nursing action would be to:
- A. Administer pain medication
- B. Suction excessive tracheobronchial secretions
- C. Assist the client to turn, deep breathe, and cough
- D. Monitor oxygen saturation
Correct answer: B
Rationale: After a segmental lung resection, the priority nursing action should be to suction excessive tracheobronchial secretions. This helps in preventing airway obstruction from secretions, ensuring the patency of the airway and optimizing respiratory function. Administering pain medication can be important but addressing airway clearance takes precedence. Assisting the client to turn, deep breathe, and cough is essential for respiratory hygiene but not the first action immediately post-op. Monitoring oxygen saturation is crucial, but ensuring airway clearance is the priority to prevent complications.
3. How should a healthcare provider handle a child with a suspected head injury who is showing signs of drowsiness?
- A. Administer pain medication
- B. Perform a full neurological assessment
- C. Allow the child to sleep
- D. Contact a specialist immediately
Correct answer: B
Rationale: When a child with a suspected head injury is showing signs of drowsiness, administering pain medication should not be the first course of action as it may mask important symptoms. Allowing the child to sleep is not recommended as they need to be monitored. Contacting a specialist immediately may delay necessary assessments. Performing a full neurological assessment is the most appropriate action because it helps evaluate the head injury's extent, identify neurological deficits, and guide further intervention or treatment.
4. A female client with borderline personality disorder is being discharged today. During morning rounds, the client complains about the aloofness of the night shift nurse and expresses joy to see the nurse on duty. Which response is best for the nurse to provide to this client’s dichotomous tendency?
- A. I am glad you like me. Which nurse was acting aloof to you?
- B. Tomorrow I will talk to that nurse about how you were treated last night.
- C. What did the night nurse do that makes you think she is aloof?
- D. I am happy that you are getting better and will be able to go home.
Correct answer: A
Rationale: Choice A is the best response as it acknowledges the client's feelings while exploring their concerns. By asking which nurse was acting aloof, the nurse shows understanding and allows the client to express their feelings further. This response validates the client's emotions and fosters a therapeutic relationship. Choice B focuses on a future action without addressing the immediate concern at hand. Choice C seeks clarification on the night nurse's behavior, which is a good approach but lacks the personal touch of Choice A. Choice D shifts the focus away from the client's current feelings and concerns, missing the opportunity to address the dichotomous thinking displayed by the client.
5. A nurse is teaching a parent how to prevent accidents while caring for a 6-month-old infant. What ability should be emphasized regarding the infant’s motor development?
- A. Sits up
- B. Rolls over
- C. Crawls short distances
- D. Stands while holding on to furniture
Correct answer: B
Rationale: The correct answer is "B: Rolls over." At 6 months, most infants can roll over, which increases the risk of falls. Emphasizing the infant's ability to roll over is crucial to highlight the need for careful supervision and accident prevention. Choices A, C, and D are incorrect because sitting up, crawling short distances, and standing while holding on to furniture typically develop later in an infant's motor skills progression and are not as directly associated with an increased risk of accidents at this stage.