HESI RN
Mental Health HESI
1. When developing a plan of care for a client admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing problem has the highest priority?
- A. Impaired comfort.
- B. Risk for injury.
- C. Ineffective breathing pattern.
- D. Ineffective coping.
Correct answer: C
Rationale: Ineffective breathing pattern is the highest priority nursing problem in this scenario because aspiration of a caustic material can lead to serious airway and respiratory issues. This poses an immediate threat to the client's life and requires urgent intervention to ensure adequate oxygenation and ventilation. The other options, such as Impaired comfort, Risk for injury, and Ineffective coping, are important but are secondary concerns compared to the critical nature of respiratory compromise in this situation.
2. Isosorbide mononitrate (Imdur) is prescribed for a client with angina pectoris. The client tells the nurse that the medication is causing a chronic headache. The nurse appropriately suggests that the client:
- A. Cut the dose in half.
- B. Discontinue the medication.
- C. Take the medication with food.
- D. Contact the healthcare provider (HCP).
Correct answer: C
Rationale: Isosorbide mononitrate can cause headaches, which usually disappear during continued therapy. Taking the medication with food or meals can help alleviate the headache. It is important to recommend this approach before considering dose adjustments or discontinuation of the medication. Contacting the healthcare provider would be necessary if the headache persists despite taking the medication with food.
3. A client who is admitted to the mental health unit reports shortness of breath and dizziness. The client tells the nurse, “I feel like I’m going to die.” Which nursing problem should the nurse include in this client’s plan of care?
- A. Mood disturbance
- B. Moderate anxiety
- C. Altered thoughts
- D. Social isolation
Correct answer: B
Rationale: The correct answer is B: Moderate anxiety. When a client presents with symptoms such as shortness of breath, dizziness, and a fear of dying, it indicates moderate anxiety. Anxiety can manifest physically with symptoms like these. Mood disturbance (choice A) refers to a change in mood, while altered thoughts (choice C) relate to cognitive changes. Social isolation (choice D) involves a lack of social interaction, which is not the primary concern in this scenario where the client is experiencing acute anxiety symptoms.
4. A psychological contract exists between staff members and nurse managers. Which of the following best describes this relationship?
- A. Nurse managers provide positive evaluations, and in turn, staff members do what managers ask of them.
- B. Nurse managers coordinate multiple departments and supervise multiple staff members.
- C. Staff members do what managers ask of them and, in turn, are rewarded through assignments, promotions, and evaluations.
- D. Nurse managers advocate for staff and support nursing roles and ethical practice.
Correct answer: C
Rationale: The correct answer is C. In a psychological contract between staff members and nurse managers, staff members are expected to fulfill the requests of managers, and in return, they are rewarded with assignments, promotions, and evaluations. This reciprocal relationship forms the basis of the psychological contract. Choices A, B, and D are incorrect because they do not accurately capture the essence of the psychological contract. While nurse managers may provide positive evaluations, coordinate departments, supervise staff, advocate for staff, and support nursing roles, these actions alone do not define the specific reciprocal nature of the psychological contract outlined in choice C.
5. A client is on nicotinic acid (niacin) for hyperlipidemia and the nurse provides instructions to the client about the medication. Which statement by the client would indicate an understanding of the instructions?
- A. It is not necessary to avoid the use of alcohol.
- B. The medication should be taken with meals to decrease flushing.
- C. Clay-colored stools are a common side effect and should not be of concern.
- D. Ibuprofen (Motrin) taken 30 minutes before the nicotinic acid should decrease the flushing.
Correct answer: D
Rationale: Aspirin or a nonsteroidal anti-inflammatory drug can be taken 30 minutes before taking the medication to decrease flushing. Alcohol consumption needs to be avoided because it will enhance this side effect. The medication should be taken with meals, this will decrease gastrointestinal upset. Taking the medication with meals has no effect on the flushing. Clay-colored stools are a sign of hepatic dysfunction and should be immediately reported to the health care provider (HCP).