HESI LPN
HESI Mental Health Practice Exam
1. An older homeless client visits the psychiatric clinic to obtain a prescription renewal for alprazolam (Xanax). During the health assessment, the client complains of chest pain. Which action should the RN take first?
- A. Refer the client to the cardiology unit.
- B. Obtain the client's blood pressure.
- C. Assess the client for substance abuse.
- D. Determine if Xanax was taken recently.
Correct answer: D
Rationale: Determining if Xanax was taken recently is crucial as it helps assess whether the chest pain is related to medication use or another issue, guiding appropriate immediate care. This action can provide essential information to address the client's current complaint effectively. Referring the client to the cardiology unit (Choice A) may be premature without assessing the Xanax use first. While obtaining the client's blood pressure (Choice B) is important, it is not the priority when the client presents with chest pain and a history of taking Xanax. Assessing the client for substance abuse (Choice C) is also important but is secondary to first determining the potential link between Xanax and the chest pain.
2. What is an episiotomy?
- A. A surgical incision of the perineum to prevent tearing during delivery.
- B. Releasing the red plug from the cervix just before crowning occurs.
- C. An incision in the abdomen with which the baby can be delivered through.
- D. The severance of the umbilical cord between mother and child.
Correct answer: A
Rationale: An episiotomy is a surgical incision of the perineum to prevent tearing during delivery. This procedure is performed to widen the vaginal opening and facilitate childbirth. Choice B is incorrect as it describes the expulsion of the mucus plug, not an episiotomy. Choice C is incorrect as it refers to a different procedure, a cesarean section, where the baby is delivered through an incision in the abdomen. Choice D is incorrect as it pertains to cutting the umbilical cord, which is not related to an episiotomy.
3. The client demonstrates an understanding of sliding scale insulin administration instructions by performing the procedure in which order?
- A. Obtain blood glucose level
- B. Verify the insulin prescription
- C. Draw insulin into insulin syringe
- D. Cleanse the selected site
Correct answer: A
Rationale: The correct order for the client to perform the procedure is to first obtain the blood glucose level. This step is crucial as it helps determine the appropriate dose of insulin based on the sliding scale. Verifying the insulin prescription, drawing insulin into the syringe, and cleansing the selected site are important steps in the process but should follow after obtaining the blood glucose level. Therefore, options B, C, and D are incorrect in terms of the initial steps required for sliding scale insulin administration.
4. The nurse volunteering at a homeless shelter to assist families with children identifies homelessness as a risk preventing families from achieving positive outcomes in life. What family theory encompasses this approach to assessing family dynamics?
- A. Duvall's developmental theory
- B. Friedman's structural functional theory
- C. Von Bertalanffy's general system theory applied to families
- D. Resiliency model of family stress, adjustment, and adaptation
Correct answer: D
Rationale: The Resiliency model of family stress, adjustment, and adaptation focuses on identifying the elements of risks and protective factors that help families achieve positive outcomes. In this scenario, the nurse recognizing homelessness as a risk aligns with the resiliency model, which emphasizes how families cope and adapt in the face of stressors. Duvall's theory primarily focuses on family life cycle stages, Friedman's theory emphasizes the roles and functions within a family structure, and Von Bertalanffy's theory looks at families as complex systems rather than specifically addressing resilience in the face of stressors.
5. A client who has a history of hyperthyroidism was initially admitted with lethargy and confusion. Which additional finding warrants the most immediate action by the nurse?
- A. Facial puffiness and periorbital edema
- B. Hematocrit of 30%
- C. Cold and dry skin
- D. Further decline in LOC
Correct answer: D
Rationale: A further decline in LOC can indicate severe complications and requires immediate attention. This change may signify worsening neurological status, which could lead to life-threatening consequences if not addressed promptly. Choices A, B, and C may also be concerning in a client with a history of hyperthyroidism, but a further decline in LOC takes priority due to its potential for rapid deterioration and the need for urgent intervention.