HESI LPN
Mental Health HESI Practice Questions
1. The nurse suspects child abuse when assessing a 3-year-old boy and noticing several small, round burns on his legs and trunk that might be the result of cigarette burns. Which parental behavior provides the greatest validation for such suspicions?
- A. The parents' explanation of how the burns occurred is different from the child's explanation of how they occurred.
- B. The parents seem to dismiss the severity of the child's burns, saying they are very small and have not posed any problem.
- C. The parents become very anxious when the nurse suggests that the child may need to be admitted for further evaluation.
- D. The parents tell the nurse that the child was burned in a house fire which is incompatible with the nurse's observation of the type of burn.
Correct answer: D
Rationale: (D) provides the most validation for suspecting child abuse. The parent's explanation (subjective data) that the child was burned in a house fire is incompatible with the objective data observed by the nurse (small, round burns on the legs and trunk). (A) relies on subjective data, and the child's explanation might not accurately reflect the situation due to various factors like age or fear. The apparent lack of concern from the parents (B) is inconclusive as the nurse's interpretation of their reaction could be subjective. While parental anxiety (C) could hint at potential child abuse, it's important to note that most parents would naturally be anxious about their child's hospitalization, making it a less definitive indicator compared to the inconsistency in the explanation provided by the parents in option (D).
2. A nurse on the postpartum unit is caring for four clients. For which of the following clients should the nurse notify the provider?
- A. A client with a urinary output of 300 ml in 8 hours
- B. A client reporting abdominal cramping during breastfeeding
- C. A client receiving magnesium sulfate with absent deep tendon reflexes
- D. A client reporting lochia rubra requiring changing perineal pads every 3 hours
Correct answer: C
Rationale: The correct answer is C because in a client receiving magnesium sulfate, absent deep tendon reflexes can indicate magnesium toxicity, which requires immediate intervention to prevent serious complications. Choices A, B, and D are common postpartum occurrences that do not typically warrant immediate provider notification. A urinary output of 300 ml in 8 hours, abdominal cramping during breastfeeding, and frequent changing of perineal pads due to lochia rubra are within the expected range of postpartum recovery and do not indicate an urgent need for provider notification.
3. A nurse is collecting data from a client who is reporting pain despite taking analgesics. Which of the following actions should the nurse take to determine the intensity of the client’s pain?
- A. Ask the client what precipitates the pain.
- B. Question the client about the location of the pain.
- C. Offer the client a pain scale to measure their pain.
- D. Use open-ended questions to identify the client’s pain sensations.
Correct answer: C
Rationale: Offering the client a pain scale is the most appropriate action to determine the intensity of the client’s pain. Pain scales help quantify the intensity of pain, providing a standardized way to assess and compare pain levels. Asking about precipitating factors (choice A) may help identify triggers but does not directly measure pain intensity. Questioning about the location of pain (choice B) helps with localization but not with quantifying intensity. Using open-ended questions (choice D) may provide insights into the quality and experience of pain but does not provide a standardized measure of intensity.
4. A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider’s prescription. Which of the following interventions should the charge nurse include?
- A. Writing a prescription for morphine sulfate as needed for pain
- B. Inserting a nasogastric (NG) tube to relieve gastric distention
- C. Showing a client how to use progressive muscle relaxation
- D. Performing a daily bath after the evening meal
Correct answer: C
Rationale: The correct answer is C. Showing a client how to use progressive muscle relaxation is an intervention that does not require a provider's prescription. This falls within the nurse's scope of practice and can be implemented to promote relaxation and reduce stress for the client. Choices A and B involve tasks that require a provider's prescription and specialized training. Writing a prescription for morphine sulfate and inserting an NG tube should only be done by authorized healthcare providers. Choice D, performing a daily bath, while within the nurse's scope, does not specifically address interventions that do not require a provider's prescription.
5. A nurse is discussing the nursing process with a newly licensed nurse. Which of the following statements by the newly licensed nurse should the nurse identify as appropriate for the planning step of the nursing process?
- A. “I will determine the most important client problems that we should address.”
- B. “I will review the past medical history on the client’s record to gather more information.”
- C. “I will carry out the new prescriptions from the provider.”
- D. “I will ask the client if their nausea has resolved.”
Correct answer: A
Rationale: In the nursing process, the planning step involves determining priorities and goals based on the identified problems. Choice A is correct as it reflects the nurse's role in identifying the most important client problems to address, which aligns with the planning phase. Choices B, C, and D are incorrect. Choice B involves data collection, which is a part of the assessment phase, not planning. Choice C pertains to the implementation of care, which occurs after the planning phase. Choice D involves evaluation of a specific intervention, not planning.