HESI LPN
HESI Mental Health 2023
1. The nurse is caring for a client who received the first-time electroconvulsive therapy (ECT) a half hour ago. Which action should the nurse implement first?
- A. Offer oral fluids.
- B. Monitor vital signs.
- C. Evaluate ECT effectiveness.
- D. Encourage group participation.
Correct answer: B
Rationale: After a client receives electroconvulsive therapy (ECT), the nurse's priority should be to monitor vital signs. This is important to ensure the client's physical stability and detect any immediate complications post-procedure. Offering oral fluids, evaluating ECT effectiveness, and encouraging group participation are all important aspects of care but monitoring vital signs takes precedence in the immediate post-ECT period.
2. The client is receiving total parenteral nutrition (TPN). Which laboratory value should the LPN/LVN monitor closely to assess for complications?
- A. Serum potassium
- B. Blood glucose
- C. Serum sodium
- D. Serum calcium
Correct answer: B
Rationale: The correct answer is B: Blood glucose. When caring for a client receiving total parenteral nutrition (TPN), monitoring blood glucose levels is essential due to the risk of hyperglycemia. TPN solutions are high in glucose, and clients may be at risk of developing hyperglycemia if the infusion rate is too high or if there are underlying issues such as insulin resistance. Monitoring serum potassium (choice A) is important but not the most crucial value to monitor in clients receiving TPN. Serum sodium (choice C) and serum calcium (choice D) are not directly impacted by TPN administration and are less likely to be affected compared to blood glucose levels.
3. The nurse is planning care for a 32-year-old male client diagnosed with HIV infection who has a history of chronic depression. Recently, the client's viral load has begun to increase rather than decrease despite his adherence to the HIV drug regimen. What should the nurse do first while taking the client's history upon admission to the hospital?
- A. Determine if the client attends a support group weekly.
- B. Hold all antidepressant medications until further notice.
- C. Ask the client if he takes St. John's Wort routinely.
- D. Have the client describe any recent changes in mood.
Correct answer: C
Rationale: The nurse's top priority upon admission is to determine if the client has been taking St. John's Wort, an herbal preparation often used for depression. St. John's Wort can interact adversely with medications used to treat HIV infection, potentially explaining the rise in the viral load (C). Asking about attending support groups (A) or recent changes in mood (D) may provide valuable information about the client's depression but is not as critical as determining St. John's Wort use. Holding antidepressant medications (B) without assessing for potential interactions can be harmful to the client.
4. The RN is serving on a medical center committee to update goals and protocols based on the national standards. Which goal most directly addresses the Healthy People 2020 initiative?
- A. Reduce ED wait time for indigent clients
- B. Providing transportation for medically challenged clients
- C. Provide access to health services
- D. Refer clients to local health department for medical services
Correct answer: C
Rationale: The correct answer is C: 'Provide access to health services.' This goal most directly addresses the Healthy People 2020 initiative, which aims to improve health care access for all individuals. Option A, 'Reduce ED wait time for indigent clients,' focuses on efficiency rather than access. Option B, 'Providing transportation for medically challenged clients,' addresses a specific need but does not cover overall health service access. Option D, 'Refer clients to local health department for medical services,' involves referral rather than direct access to services.
5. Which lab result should be abnormal in a child with hemophilia?
- A. Prothrombin time
- B. Bleeding time
- C. Platelet count
- D. Partial thromboplastin time
Correct answer: D
Rationale: In a child with hemophilia, the lab result that should be abnormal is the partial thromboplastin time (PTT). Hemophilia is a disorder that affects the clotting factors in the intrinsic pathway of coagulation, leading to a prolonged PTT. Prothrombin time (Choice A) assesses the extrinsic pathway and should be normal in hemophilia. Bleeding time (Choice B) evaluates platelet function, which is typically normal in hemophilia. Platelet count (Choice C) measures the number of platelets and is not directly affected by hemophilia.