HESI LPN
HESI Mental Health
1. A client with generalized anxiety disorder is being taught about buspirone (BuSpar) by a nurse. Which statement by the client indicates a need for further teaching?
- A. I should take this medication on an empty stomach.
- B. It may take several weeks before I feel better.
- C. This medication does not cause dependence.
- D. I can drink alcohol while taking this medication.
Correct answer: D
Rationale: The statement 'I can drink alcohol while taking this medication' (D) indicates a need for further teaching. Clients should avoid alcohol while taking buspirone because it can increase the risk of side effects such as dizziness and drowsiness. Choices A, B, and C are correct statements regarding buspirone and do not require further teaching.
2. While performing a visual inspection of a 30-year-old woman in active labor, you can see the umbilical cord at the vaginal opening. After providing high concentration oxygen, you should next
- A. massage the uterus to facilitate delivery of the fetus
- B. relieve pressure from the cord with your gloved fingers
- C. place the mother on her left side and provide rapid transport
- D. elevate the mother's lower extremities and provide immediate transport
Correct answer: B
Rationale: In the scenario described, when the umbilical cord is visible at the vaginal opening, the priority is to relieve pressure from the cord with gloved fingers. This action helps prevent cord compression and ensures continued oxygenation to the fetus, which is crucial for the baby's well-being. Massaging the uterus or elevating the mother's lower extremities is not the correct course of action in this situation and may potentially worsen the condition. Placing the mother on her left side and providing rapid transport is not the immediate step needed to address the visible umbilical cord; relieving pressure from the cord takes precedence to maintain fetal oxygen supply.
3. A client with hyperkalemia is being treated in the emergency department. Which medication should the nurse prepare to administer?
- A. Potassium chloride
- B. Calcium gluconate
- C. Magnesium sulfate
- D. Sodium bicarbonate
Correct answer: B
Rationale: The correct answer is B, Calcium gluconate. In hyperkalemia, where potassium levels are elevated, calcium gluconate is administered to stabilize the myocardial cell membrane and protect the heart from potential arrhythmias. Potassium chloride (choice A) would worsen the condition by further increasing potassium levels. Magnesium sulfate (choice C) is not the primary treatment for hyperkalemia. Sodium bicarbonate (choice D) is used in metabolic acidosis, not specifically for hyperkalemia.
4. The healthcare professional is assessing a client who is post-operative following abdominal surgery. Which assessment finding would require immediate intervention?
- A. Absent bowel sounds
- B. Pain level of 8/10
- C. Temperature of 100.4°F
- D. Saturated abdominal dressing
Correct answer: D
Rationale: A saturated abdominal dressing may indicate active bleeding or other complications that require immediate intervention. This finding suggests a potential surgical site issue that needs urgent attention to prevent further complications. Absent bowel sounds, pain level, and a slightly elevated temperature are common post-operative findings that may not necessarily require immediate intervention compared to a saturated abdominal dressing. Absent bowel sounds can be common after surgery due to anesthesia but may resolve with time. Pain and slightly elevated temperature are expected post-operative findings that can be managed with appropriate pain relief and monitoring. However, a saturated abdominal dressing indicates a potential ongoing issue at the surgical site that needs prompt assessment and intervention to prevent complications.
5. A healthcare professional is planning care for a female client who has an indwelling urinary catheter. Which of the following actions should the healthcare professional include in the plan?
- A. Empty the drainage bag at least every 8 hours
- B. Keep the drainage bag below the level of the bladder
- C. Use sterile technique to collect a specimen from the drainage system
- D. Secure the catheter to the lower abdomen with a securement device
Correct answer: B
Rationale: The correct action to include in the plan is to keep the drainage bag below the level of the bladder. This positioning helps ensure proper drainage and prevents backflow of urine into the bladder, reducing the risk of urinary tract infections. Emptying the drainage bag regularly is important, typically every 4-8 hours or when it is half-full, to maintain adequate flow and prevent infection (Choice A is incorrect). Using a sterile technique to collect specimens from the drainage system is crucial to prevent introducing pathogens into the urinary tract, so clean technique should not be used (Choice C is incorrect). Taping the catheter to the lower abdomen is not recommended as it can cause tension on the catheter, leading to discomfort and potential trauma to the urethra (Choice D is incorrect).