HESI RN
Mental Health HESI
1. The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. What information should the nurse explore in-depth with the client based on this screening tool?
- A. Cancer screening result and gastritis daily alcohol intake.
- B. Consumption, liver enzyme gastrointestinal complaints, and bleeding.
- C. Efforts to cut down, annoyance with questions, guilt, and drinking as an eye-opener.
- D. Minimizes drinking, frequently misses family events, guilt about drinking, and amount of daily intake.
Correct answer: C
Rationale: The CAGE questionnaire focuses on the client’s self-perception and behaviors related to drinking, such as efforts to cut down and guilt.
2. The client has received a new diagnosis of heart failure, and the nurse is providing dietary management education. Which instruction should the nurse include?
- A. Increase intake of foods high in potassium.
- B. Avoid foods high in sodium.
- C. Limit fluid intake to 1.5 liters per day.
- D. Increase intake of foods high in vitamin K.
Correct answer: B
Rationale: Avoiding foods high in sodium (choice B) is essential for clients with heart failure to prevent fluid retention and decrease the strain on the heart. High sodium intake can lead to fluid buildup, exacerbating heart failure symptoms. Increasing potassium intake (choice A) can be harmful in heart failure if not monitored closely as it can affect heart rhythm. Limiting fluid intake (choice C) may be necessary in some cases, but the specific amount should be individualized based on the client's condition. Increasing vitamin K intake (choice D) is not a primary concern in heart failure management and is more relevant for clients on anticoagulants to manage blood clotting.
3. A patient taking trimethoprim-sulfamethoxazole (TMP-SMX) to treat a urinary tract infection complains of a sore throat. The nurse will contact the provider to request an order for which laboratory test(s)?
- A. Complete blood count with differential
- B. Throat culture
- C. Urinalysis
- D. Coagulation studies
Correct answer: A
Rationale: When a patient taking trimethoprim-sulfamethoxazole (TMP-SMX) for a urinary tract infection presents with a sore throat, the nurse should request a complete blood count with differential. TMP-SMX can cause life-threatening adverse effects such as agranulocytosis, a condition characterized by a low white blood cell count, which can manifest as a sore throat. Ordering a complete blood count with differential helps assess the patient's white blood cell count to detect any potential serious adverse effects. Throat culture (Choice B) is not indicated unless there are specific signs of a throat infection. Urinalysis (Choice C) is not relevant for assessing a sore throat. Coagulation studies (Choice D) are not typically indicated for a sore throat symptom.
4. What is the role of the corpus luteum during the menstrual cycle?
- A. The corpus luteum produces estrogen to maintain the endometrium.
- B. The corpus luteum produces progesterone to maintain the endometrium.
- C. The corpus luteum produces testosterone to inhibit ovulation.
- D. The corpus luteum has no significant role during the menstrual cycle.
Correct answer: B
Rationale: The correct answer is B: The corpus luteum produces progesterone to maintain the endometrium during the menstrual cycle. This hormone helps prepare the uterine lining for implantation in case fertilization occurs. Choice A is incorrect because estrogen is mainly produced by the developing follicles in the ovaries. Choice C is incorrect as testosterone is produced in smaller amounts by the ovaries and adrenal glands but does not play a significant role in maintaining the endometrium. Choice D is incorrect as the corpus luteum plays a crucial role in producing progesterone to support the endometrium.
5. The nurse must delegate some aspects of a homebound client's care to a home health aide. Which intervention should the nurse delegate to the home health aide?
- A. evaluating a pressure sore
- B. applying a prosthetic device
- C. performing a sterile dressing change
- D. assessing the client's need for an elevated toilet seat
Correct answer: B
Rationale: The correct answer is B: applying a prosthetic device. Home health aides are trained and authorized to assist with the application and management of prosthetic devices for clients. Evaluating a pressure sore (choice A) requires clinical assessment and judgment typically performed by a licensed healthcare provider such as a nurse. Performing a sterile dressing change (choice C) involves aseptic technique and wound care skills that are usually performed by licensed healthcare professionals. Assessing the client's need for an elevated toilet seat (choice D) involves a level of assessment and decision-making that is beyond the scope of practice for a home health aide.