HESI LPN
HESI Mental Health
1. A nurse is providing discharge teaching to a client with schizophrenia who is prescribed clozapine (Clozaril). Which information should the nurse include?
- A. You need to come in for regular blood tests.
- B. This medication can cause weight loss.
- C. You can stop taking this medication once you feel better.
- D. Avoid foods high in tyramine while on this medication.
Correct answer: A
Rationale: The correct answer is A: 'You need to come in for regular blood tests.' Clozapine can cause agranulocytosis, a potentially life-threatening condition, so regular blood tests are required to monitor the client's white blood cell count. Choice B is incorrect because clozapine is associated with weight gain, not weight loss. Choice C is incorrect because the client should never stop taking clozapine abruptly due to the risk of withdrawal symptoms and symptom relapse. Choice D is incorrect because avoiding foods high in tyramine is typically associated with MAOIs, not clozapine.
2. A client reports new onset hearing loss bilaterally after taking a medication with known ototoxic effects. Which type of hearing loss should the nurse suspect?
- A. Conductive
- B. Sensorineural
- C. Mixed
- D. Central
Correct answer: B
Rationale: The correct answer is B: Sensorineural. Ototoxic medications can lead to sensorineural hearing loss by affecting the inner ear or auditory nerve. Conductive hearing loss is related to issues in the middle or outer ear, not typically caused by ototoxic medications. Mixed hearing loss is a combination of conductive and sensorineural components. Central hearing loss is related to the central nervous system, not commonly caused by ototoxic medications. Therefore, in this case, the nurse should suspect sensorineural hearing loss.
3. A healthcare professional is assessing a child with suspected appendicitis. What clinical manifestation is the healthcare professional likely to observe?
- A. Right lower quadrant pain
- B. Left lower quadrant pain
- C. Rebound tenderness
- D. Epigastric pain
Correct answer: A
Rationale: Right lower quadrant pain is a characteristic clinical manifestation of appendicitis. The appendix is typically located in the right lower quadrant of the abdomen, so pain in this area is a common symptom. Left lower quadrant pain (Choice B) is less likely in cases of appendicitis. Rebound tenderness (Choice C) is a sign of peritonitis, not specific to appendicitis. Epigastric pain (Choice D) is more indicative of upper gastrointestinal issues rather than appendicitis.
4. Which action should the nurse implement first for a client experiencing alcohol withdrawal?
- A. Apply vest or extremity restraints.
- B. Give an alpha-adrenergic blocker.
- C. Provide a diet high in protein and calories.
- D. Prepare the environment to prevent self-injury.
Correct answer: D
Rationale: The correct action for the nurse to implement first for a client experiencing alcohol withdrawal is to prepare the environment to prevent self-injury. Clients undergoing alcohol withdrawal are at risk of seizures and other symptoms that may lead to self-harm. By ensuring a safe environment, the nurse can mitigate the risk of injury. Applying restraints (Choice A) should only be considered if less restrictive measures fail, as restraints can agitate the client further. Giving an alpha-adrenergic blocker (Choice B) may be part of the treatment plan for alcohol withdrawal but is not the first action to take. Providing a diet high in protein and calories (Choice C) is important for overall health but is not the priority when addressing immediate safety concerns.
5. A client is receiving continuous IV fluid therapy via a peripheral vein in the left forearm. Which of the following findings indicates that the client has developed phlebitis at the IV site?
- A. Erythema along the path of the vein
- B. Pitting edema at the insertion site
- C. Coolness of the client’s left forearm
- D. Pallor of the client’s left forearm
Correct answer: A
Rationale: Erythema (redness) along the path of the vein is a classic sign of phlebitis, indicating inflammation of the vein. This occurs due to irritation or infection at the IV site. Pitting edema (choice B) is not typically associated with phlebitis but suggests fluid overload or poor circulation. Coolness (choice C) and pallor (choice D) of the forearm are not characteristic signs of phlebitis but may indicate impaired circulation or reduced blood flow to the area.