HESI RN
Quizlet HESI Mental Health
1. The healthcare provider is assessing a client who has been taking an antidepressant for several months. Which symptom would suggest that the medication is working?
- A. Improved mood and increased energy.
- B. Increased appetite and weight gain.
- C. Decreased anxiety and agitation.
- D. Enhanced sleep patterns and vivid dreams.
Correct answer: A
Rationale: When assessing the effectiveness of an antidepressant, improved mood and increased energy are positive indicators that the medication is working. Choice B, increased appetite and weight gain, are more commonly associated with side effects of some antidepressants, such as certain tricyclic antidepressants. Choice C, decreased anxiety and agitation, could be related to the therapeutic effects of antidepressants in treating anxiety disorders but may not specifically indicate the efficacy of the medication for depression. Choice D, enhanced sleep patterns and vivid dreams, while changes in sleep patterns can be influenced by antidepressants, they are not the primary indicators of antidepressant efficacy. Therefore, the correct choice is A as it directly reflects the desired outcomes of antidepressant therapy.
2. The client is 5 feet from the bathroom door when he states, 'I feel faint.' Before the nurse can get the client to a chair, the client starts to fall. What is the priority action for the nurse to take?
- A. Check the client's carotid pulse.
- B. Encourage the client to get to the toilet.
- C. In a loud voice, call for help.
- D. Gently lower the client to the floor.
Correct answer: D
Rationale: The priority action for the nurse in this situation is to gently lower the client to the floor. This action helps prevent injury to both the client and the nurse. It is important to ensure a safe environment and protect the client from falling, as well as to maintain the nurse's own safety while providing care.
3. The charge nurse of the medical-surgical unit is making staff assignments. Which staff member should be assigned to a client with chronic kidney disease who is exhibiting a low-grade fever and a pericardial friction rub?
- A. Registered nurse who just floated from the surgical unit
- B. Registered nurse who just floated from the dialysis unit
- C. Registered nurse who was assigned the same client yesterday
- D. Licensed practical nurse with 5 years of experience on this floor
Correct answer: C
Rationale: The client is exhibiting symptoms of pericarditis, which can occur with chronic kidney disease. Continuity of care is crucial to assess subtle changes in clients' conditions. Therefore, the registered nurse (RN) who previously cared for this client should be assigned again. Float nurses may lack knowledge of the unit and its clients, potentially leading to oversight of critical details. The licensed practical nurse, while experienced, may not possess the advanced assessment skills and education level of an RN to effectively evaluate and manage pericarditis in this client.
4. A client is suspected of being poisoned and presents with symmetric, descending flaccid paralysis, blurred vision, double vision, and dry mouth. The nurse should consider these findings consistent with which potential bioterrorism agent?
- A. ricin
- B. botulism toxin
- C. sulfur mustard
- D. yersinia pestis
Correct answer: B
Rationale: The correct answer is B: botulism toxin. The symptoms described, including symmetric, descending flaccid paralysis, blurred vision, double vision, and dry mouth, are classic manifestations of botulism, which is caused by a toxin produced by Clostridium botulinum. This toxin affects the nervous system, leading to muscle weakness and paralysis. Choice A, ricin, typically presents with gastrointestinal symptoms and organ failure. Choice C, sulfur mustard, causes blistering skin and respiratory issues. Choice D, yersinia pestis, is associated with the plague and presents with fever, chills, weakness, and swollen lymph nodes.
5. A nurse teaches clients about the difference between urge incontinence and stress incontinence. Which statements should the nurse include in this education? (Select all that apply.)
- A. Urge incontinence involves a post-void residual volume less than 50 mL.
- B. Stress incontinence occurs due to weak pelvic floor muscles.
- C. Stress incontinence usually occurs in people with dementia.
- D. Urge incontinence can be managed by increasing fluid intake.
Correct answer: B
Rationale: The correct statement to include in the education about urge incontinence and stress incontinence is choice B. Stress incontinence occurs due to weak pelvic floor muscles or urethral sphincter, leading to the inability to tighten the urethra sufficiently to overcome increased detrusor pressure. This condition is common after childbirth when pelvic muscles are stretched and weakened. Urge incontinence, on the other hand, is characterized by the inability to suppress the contraction signal from the detrusor muscle. It is often associated with abnormal detrusor contractions, which can be due to neurological abnormalities rather than post-void residual volume. Choice A is incorrect because urge incontinence is not defined by post-void residual volume. Choice C is incorrect as stress incontinence is not usually linked to dementia. Choice D is incorrect because increasing fluid intake is not a management strategy for urge incontinence.