HESI LPN
Mental Health HESI 2023
1. A nurse working in the emergency room of a children's hospital admits a child whose injuries could have resulted from abuse. Which statement most accurately describes the nurse's responsibility in cases of suspected child abuse?
- A. Obtain objective data such as x-rays before reporting suspicions.
- B. Confirm suspicions of abuse with the physician.
- C. Report any case of suspected child abuse.
- D. Document injuries to confirm suspected abuse.
Correct answer: C
Rationale: The correct answer is C: 'Report any case of suspected child abuse.' Nurses are mandated reporters, which means they are legally obligated to report any suspicions of child abuse to appropriate authorities to ensure the child's safety. This responsibility overrides the need to gather additional data or confirm suspicions with others before reporting. Choice A is incorrect because delaying reporting to gather more data may risk the child's safety. Choice B is incorrect because reporting suspicions promptly is crucial, and waiting to confirm with another healthcare provider could delay necessary intervention. Choice D is incorrect as the priority is to report suspicions promptly rather than focusing on documenting injuries to confirm abuse.
2. In what order should the unit manager implement interventions to address the UAP’s behavior after they leave the unit without notifying the staff?
- A. Note date and time of the behavior.
- B. Discuss the issue privately with the UAP.
- C. Plan for scheduled break times.
- D. Evaluate the UAP for signs of improvement.
Correct answer: A
Rationale: The correct order for the unit manager to implement interventions to address the UAP's behavior is to first note the date and time of the behavior. Proper documentation is crucial as it provides a factual record of the incident. This documentation can be used to address the behavior effectively and to track any patterns or improvements in the future. Discussing the issue with the UAP privately (choice B) should come after documenting the behavior. Planning for scheduled break times (choice C) is unrelated to the situation described and does not address the UAP's behavior of leaving without notifying the staff. Evaluating the UAP for signs of improvement (choice D) can only be done effectively after the behavior has been addressed and interventions have been implemented.
3. In addition to disturbances in mental awareness and orientation, a client with cognitive impairment is also likely to show loss of ability in
- A. Hearing, speech, and sight
- B. Endurance, strength, and mobility
- C. Learning, creativity, and judgment
- D. Balance, flexibility, and coordination
Correct answer: C
Rationale: Individuals with cognitive impairment often experience difficulties in learning new information, creative thinking, and making sound judgments. Loss of ability in hearing, speech, and sight (Choice A) is more closely related to sensory impairments rather than cognitive impairment. Endurance, strength, and mobility (Choice B) are more associated with physical capabilities rather than cognitive functions. Balance, flexibility, and coordination (Choice D) are related to motor skills and physical coordination, not cognitive impairment.
4. The nurse is assessing a client who reports sudden onset of severe eye pain and blurred vision. What is the priority nursing intervention?
- A. Administer prescribed pain medication.
- B. Notify the healthcare provider immediately.
- C. Place an eye patch over the affected eye.
- D. Prepare the client for a CT scan.
Correct answer: B
Rationale: The correct answer is to notify the healthcare provider immediately (Choice B). Sudden severe eye pain and blurred vision can indicate acute angle-closure glaucoma, which is a medical emergency requiring prompt evaluation and treatment to prevent vision loss. Administering pain medication (Choice A) may provide temporary relief but does not address the underlying cause. Placing an eye patch (Choice C) may not be appropriate without knowing the exact cause of the symptoms. Preparing for a CT scan (Choice D) is not the immediate priority in this situation where urgent medical attention is needed.
5. The nurse is assessing a 3-month-old infant who had a pylorotomy yesterday. This child should be medicated for pain based on which finding?
- A. Restlessness
- B. Clenched Fist
- C. Increased pulse rate
- D. Increased respiratory rate
Correct answer: A
Rationale: In infants, restlessness can be a significant indicator of discomfort or pain, necessitating appropriate pain management. While choices B, C, and D can also be associated with pain, restlessness is a more general and reliable indicator in this scenario. A clenched fist might indicate pain or distress, but it is not as specific as restlessness in assessing pain in infants. Increased pulse rate and respiratory rate can be influenced by various factors other than pain, making them less reliable indicators of pain in this context.