HESI LPN
HESI Mental Health
1. When developing a plan of care for a client in the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing diagnosis has the highest priority?
- A. Risk for injury.
- B. Ineffective coping mechanisms.
- C. Alteration in comfort.
- D. Ineffective breathing patterns.
Correct answer: D
Rationale: When a client aspirates a caustic material, the priority nursing diagnosis should focus on addressing physiological concerns, particularly related to breathing patterns. Aspiration of caustic material can lead to airway compromise, respiratory distress, and potential lung damage. Therefore, monitoring and addressing ineffective breathing patterns are crucial for ensuring the client's immediate safety and well-being. Choices A, B, and C are important considerations in psychiatric care but are secondary to the critical physiological issue of ineffective breathing patterns in this scenario.
2. What is the typical sex chromosome pattern for females?
- A. XX
- B. XYY
- C. XY
- D. XXY
Correct answer: A
Rationale: The typical sex chromosome pattern for females is XX. Females have two X chromosomes, which is represented as XX. Choice B (XYY) is incorrect as it represents the sex chromosome pattern for males with an extra Y chromosome. Choice C (XY) is the sex chromosome pattern for males. Choice D (XXY) represents a genetic disorder known as Klinefelter syndrome, where males have an extra X chromosome.
3. What should be done when caring for a client who died?
- A. Obtain orders, Remove tubes, Wash client, Ask family, Place tags.
- B. Wash client, Obtain orders, Place tags, Remove tubes, Ask family.
- C. Remove tubes, Obtain orders, Ask family, Place tags, Wash client.
- D. Ask family, Place tags, Wash client, Remove tubes, Obtain orders.
Correct answer: A
Rationale: When caring for a deceased client, the correct sequence of actions involves first obtaining any necessary orders, then removing tubes, washing the client, asking the family for specific requests, and finally placing identification tags. This order ensures proper care and respect for the deceased individual. Option A presents the correct order of actions. Choice B is incorrect because washing the client should be done after removing tubes. Choice C is incorrect as it does not follow the correct order of actions. Choice D is incorrect because asking the family should be done after caring for the client's body, not before.
4. A client has undergone an allogeneic stem cell transplant, and a nurse is initiating a protective environment. Which precaution should the nurse plan for this client?
- A. Ensure the client wears a mask when outside the room if there is construction in the area.
- B. Place the client in a room with other immunocompromised patients.
- C. Allow the client to visit public areas freely.
- D. Ensure the client does not need any special precautions.
Correct answer: A
Rationale: For a client who has undergone an allogeneic stem cell transplant, it is crucial to maintain a protective environment to prevent infections. Wearing a mask when outside the room, especially if there is construction in the area, helps reduce the risk of exposure to harmful pathogens. This precaution is essential as the client's immune system is compromised post-transplant. Placing the client in a room with other immunocompromised patients (choice B) would increase the risk of infections as it exposes the client to a higher pathogen load. Allowing the client to visit public areas freely (choice C) is not recommended due to the higher risk of exposure to infections. Ensuring the client does not need any special precautions (choice D) is incorrect because clients post allogeneic stem cell transplant require protective measures to prevent complications.
5. Which action is most important for maintaining sterility when donning sterile gloves?
- A. Maintain thumbs at a ninety-degree angle.
- B. Hold hands with fingers pointing downward while gloving.
- C. Keep gloved hands above the elbows.
- D. Put the glove on the dominant hand first.
Correct answer: C
Rationale: The most crucial action for maintaining sterility when donning sterile gloves is to keep gloved hands above the elbows. This practice is essential to prevent potential contamination and maintain a sterile field. Choices A, maintaining thumbs at a ninety-degree angle, and B, holding hands with fingers pointing downward while gloving, are not as critical as keeping hands above the elbows for maintaining sterility. Choice D, putting the glove on the dominant hand first, is not as important as ensuring that gloved hands are kept above the elbows to maintain sterility.