HESI LPN
HESI Mental Health
1. Which information should the LPN/LVN exclude in the nursing plan of care for a client with obsessive-compulsive disorder (OCD)?
- A. The medical diagnosis of the client
- B. Individualized goals and objectives
- C. Attendance at group therapy sessions
- D. Self-care measures to improve hygiene
Correct answer: A
Rationale: The correct answer is A because including the medical diagnosis of the client in the nursing plan is redundant as the healthcare team is already aware of the diagnosis. The nursing plan of care for a client with OCD should focus on individualized goals, objectives, attendance at group therapy sessions, and self-care measures to improve hygiene. These components directly contribute to addressing the client's needs and promoting recovery. Therefore, the medical diagnosis does not need to be included in the nursing plan as it does not actively guide the day-to-day care and interventions for the client.
2. A 16-year-old female client returns to the clinic because she is pregnant for the third time by a new boyfriend. Which vaccine should the nurse plan to administer?
- A. Measles-mumps-rubella.
- B. Hepatitis B.
- C. Human papillomavirus.
- D. Pneumococcal.
Correct answer: B
Rationale: The correct answer is B: Hepatitis B. The Hepatitis B vaccine is crucial for pregnant women as it helps prevent transmission of the virus to the baby during childbirth. Measles-mumps-rubella vaccine (choice A) is not directly related to the current situation of the client being pregnant. Human papillomavirus vaccine (choice C) is recommended for adolescents but is not specifically indicated in this case. Pneumococcal vaccine (choice D) is not a priority in this scenario compared to Hepatitis B, which is crucial for preventing vertical transmission.
3. A client with chronic kidney disease is prescribed sucroferric oxyhydroxide. What potential side effect should the nurse monitor for?
- A. Diarrhea
- B. Constipation
- C. Nausea
- D. Hyperphosphatemia
Correct answer: A
Rationale: Sucroferric oxyhydroxide is known to cause diarrhea as a side effect. Therefore, the nurse should closely monitor the client for any signs of diarrhea while on this medication to ensure timely intervention and management.
4. A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago but feels fine now. What action is best for the LPN/LVN to take?
- A. Record the coughing incident. No further action is required at this time.
- B. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider.
- C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.
- D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling.
Correct answer: C
Rationale: After a client experiences severe coughing following nasogastric tube feedings, it is crucial to verify proper tube placement. Checking the pH of fluid withdrawn from the tube helps confirm the tube's correct positioning. Option A is incorrect because further action is necessary to ensure the client's safety. Option B is inappropriate as it suggests stopping the feeding without assessing the tube's placement. Option D is incorrect as injecting air into the tube may lead to further complications if the tube is not positioned correctly.
5. Which organization is primarily responsible for global public health?
- A. World Health Organization (WHO)
- B. Centers for Disease Control and Prevention (CDC)
- C. National Institutes of Health (NIH)
- D. United Nations (UN)
Correct answer: A
Rationale: The correct answer is A: World Health Organization (WHO). The WHO is the primary organization responsible for global public health initiatives, coordinating international health efforts, setting norms and standards, providing technical support, and monitoring health trends. Choices B, C, and D are incorrect because while they play significant roles in health and global affairs, they do not have the primary responsibility for global public health like the WHO does.