HESI LPN
HESI Mental Health
1. A nurse is caring for a client with major depressive disorder who is withdrawn and refuses to participate in group activities. What is the best nursing intervention?
- A. Encourage the client to attend at least one group session.
- B. Respect the client's wish to remain isolated.
- C. Arrange for individual therapy sessions.
- D. Offer the client a list of activities to choose from.
Correct answer: A
Rationale: Encouraging the client to attend at least one group session is the best nursing intervention in this scenario. By gently encouraging participation, the nurse can help the client start to engage with others, which may gradually improve their mood and social interaction. Choice B, respecting the client's wish to remain isolated, may further exacerbate the client's withdrawal and depression by reinforcing avoidance behavior. Choice C, arranging for individual therapy sessions, can be beneficial but may not address the specific need for social interaction. Choice D, offering a list of activities to choose from, does not directly address the client's difficulty in participating in group activities and may not provide the necessary support in overcoming social withdrawal.
2. The parents of a child who is scheduled for open-heart surgery ask why their child must be subjected to chest tubes after surgery. What should the nurse consider before responding in language the parents will understand?
- A. They will increase tidal volumes.
- B. Drainage of air and fluid will be facilitated.
- C. They will maintain positive intrapleural pressure.
- D. Pressure on the pericardium and chest wall will be regulated.
Correct answer: B
Rationale: Chest tubes are used to drain air and fluid from the chest cavity to prevent complications such as pneumothorax or cardiac tamponade after surgery. Choice A is incorrect as chest tubes are not used to increase tidal volumes. Choice C is incorrect as chest tubes do not maintain positive intrapleural pressure; instead, they assist in removing excess air or fluid. Choice D is incorrect as chest tubes do not regulate pressure on the pericardium and chest wall; they primarily aid in drainage.
3. Which structures are located in the subcutaneous layer of the skin?
- A. Sebaceous and sweat glands
- B. Melanin and keratin
- C. Sensory receptors and hair follicles
- D. Adipose cells and blood vessels
Correct answer: D
Rationale: The correct answer is D: Adipose cells and blood vessels. The subcutaneous layer, also known as the hypodermis, primarily consists of adipose (fat) tissue and blood vessels. Adipose tissue provides insulation, energy storage, and cushioning, while blood vessels supply nutrients and oxygen. Sebaceous and sweat glands are located in the dermis, which is the layer beneath the epidermis. Melanin and keratin are components of the epidermis, responsible for skin color and waterproofing, respectively. Sensory receptors and hair follicles are found in the dermis and extend into the subcutaneous layer but are not exclusive to it.
4. In planning nursing care for a bedfast client, which factor is most likely to contribute to the development of deep vein thrombosis (DVT) in an immobile client?
- A. Atherosclerotic plaque formation.
- B. Stasis of blood flow.
- C. Endothelial damage.
- D. Atherosclerotic vessel changes.
Correct answer: B
Rationale: The correct answer is B: Stasis of blood flow. Stasis of blood flow in immobile clients increases the risk of DVT, as lack of movement can cause blood to pool and clot. Atherosclerotic plaque formation (choice A) and atherosclerotic vessel changes (choice D) are more related to arterial diseases rather than DVT. Endothelial damage (choice C) can contribute to the development of DVT, but in an immobile client, stasis of blood flow is the most significant factor.
5. The client with gastroesophageal reflux disease (GERD) is receiving dietary modification education from the nurse. Which statement by the client indicates a need for further teaching?
- A. I will avoid eating large meals before bedtime.
- B. I will limit coffee consumption to the morning hours.
- C. I will elevate the head of my bed while sleeping.
- D. I will avoid spicy and acidic foods.
Correct answer: B
Rationale: The correct answer is B. Clients with GERD should avoid coffee as it can relax the lower esophageal sphincter and exacerbate symptoms. Limiting coffee consumption to the morning hours may not be sufficient, as coffee can still contribute to GERD symptoms throughout the day. Choices A, C, and D are all appropriate strategies for managing GERD symptoms. Avoiding large meals before bedtime, elevating the head of the bed while sleeping, and steering clear of spicy and acidic foods are all recommended practices to help alleviate GERD symptoms. Therefore, the client's statement in option B indicates a need for further teaching to completely address dietary modifications for managing GERD.