HESI RN
Mental Health HESI Quizlet
1. When changing the dressing for a client diagnosed with borderline personality disorder who has self-inflicted lacerations on the abdomen, which approach should the RN use?
- A. Provide detailed and thorough explanations while cleansing the wound.
- B. Perform the dressing change in a non-judgmental manner.
- C. Ask why the client cut their own abdomen in a non-threatening manner.
- D. Request assistance from another staff member for the dressing change.
Correct answer: B
Rationale: The correct approach for the RN when changing the dressing for a client diagnosed with borderline personality disorder who has self-inflicted lacerations on the abdomen is to perform the dressing change in a non-judgmental manner. This approach helps maintain therapeutic rapport and respect for the client's situation. Choice A is incorrect because providing detailed and thorough explanations may not be as important as maintaining a non-judgmental attitude. Choice C is incorrect because asking why the client cut their own abdomen may come across as accusatory or threatening, which can be counterproductive in building trust. Choice D is incorrect because the RN should be equipped to handle the dressing change independently while ensuring a supportive and non-judgmental environment for the client.
2. A client is hospitalized in the oliguric phase of acute kidney injury (AKI) and is receiving tube feedings. The nurse is teaching the client’s spouse about the kidney-specific formulation for the enteral solution compared to standard formulas. What components should be discussed in the teaching plan? (Select all that apply.)
- A. Lower sodium
- B. Lower potassium
- C. Higher phosphorus
- D. A & B
Correct answer: D
Rationale: In the oliguric phase of acute kidney injury (AKI), clients may require tube feedings with kidney-specific formulas. These formulations are lower in sodium and potassium, which are crucial considerations due to impaired kidney function. Higher phosphorus content is not a feature of kidney-specific formulations for AKI. Therefore, options A and B (lower sodium and lower potassium) should be discussed in the teaching plan. Option C, higher phosphorus, is incorrect as kidney-specific formulas are not intended to be higher in phosphorus content for AKI patients.
3. A client has had a pulmonary artery catheter inserted. In performing hemodynamic monitoring with the catheter, the nurse will wedge the catheter to gain information about which of the following?
- A. Cardiac output.
- B. Right atrial blood flow.
- C. Left end-diastolic pressure.
- D. Cardiac index.
Correct answer: C
Rationale: The correct answer is C: Left end-diastolic pressure. Wedging the pulmonary artery catheter allows the nurse to obtain the pulmonary artery wedge pressure, which reflects the left end-diastolic pressure. This pressure is essential in assessing left ventricular function and diagnosing conditions like heart failure. Choices A, B, and D are incorrect because wedging the catheter does not directly provide information about cardiac output, right atrial blood flow, or cardiac index.
4. A client is starting urinary bladder training. Which statement should the nurse include in this client’s teaching?
- A. Use the toilet when you first feel the urge, rather than at specific intervals.
- B. Try to consciously hold your urine until the scheduled toileting time.
- C. Initially try to use the toilet at least every half hour for the first 24 hours.
- D. The toileting interval can be increased once you have been continent for a week.
Correct answer: B
Rationale: In urinary bladder training, the client should be taught to try to consciously hold their urine until the scheduled toileting time. This helps in training the bladder to hold urine for longer periods. Option A is incorrect because the goal is to consciously hold urine, not void immediately. Option C is incorrect as toileting at least every half hour may not promote bladder training. Option D is incorrect as increasing the toileting interval should be based on the client's comfort and progress, not just after being continent for a week.
5. The RN is admitting a male client who takes lithium carbonate (Eskalith) twice a day. Which information should the RN report to the HCP immediately?
- A. Short-term memory loss.
- B. Five-pound weight gain.
- C. Decreased affect.
- D. Nausea and vomiting.
Correct answer: D
Rationale: Nausea and vomiting are signs of potential lithium toxicity, which is a serious condition requiring immediate attention. These symptoms can indicate a dangerous level of lithium in the body that can lead to severe complications. Short-term memory loss (A), five-pound weight gain (B), and decreased affect (C) are important to monitor but are not as immediately concerning as symptoms of potential toxicity like nausea and vomiting.