HESI RN
Mental Health HESI
1. When preparing to administer a prescribed medication to a homeless male at a community psychiatric clinic, the client tells the nurse that he usually takes a different dosage. What action should the nurse take?
- A. Tell him to take the medication then verify the dosage at the next healthcare team meeting.
- B. Withhold the medication until the dosage can be confirmed.
- C. Inform him that he may refuse the medication and document whether or not he takes it.
- D. Explain to the client that the dosage has been changed.
Correct answer: B
Rationale: Withholding the medication until the dosage can be confirmed ensures patient safety and accuracy in treatment.
2. The provider has ordered Kayexalate and sorbitol to be administered to a patient. The nurse caring for this patient would expect which serum electrolyte values prior to administration of this therapy?
- A. Sodium 125 mEq/L and potassium 2.5 mEq/L
- B. Sodium 150 mEq/L and potassium 3.6 mEq/L
- C. Sodium 135 mEq/L and potassium 6.9 mEq/L
- D. Sodium 148 mEq/L and potassium 5.5 mEq/L
Correct answer: C
Rationale: Severe hyperkalemia, with a potassium level of 6.9 mEq/L, requires aggressive treatment with Kayexalate and sorbitol to increase the body’s excretion of potassium. The normal range for serum potassium is 3.5 to 5.5 mEq/L, so patients with the other potassium levels would not be treated aggressively or would need potassium supplementation. Therefore, option C (Sodium 135 mEq/L and potassium 6.9 mEq/L) is the correct choice as it indicates severe hyperkalemia warranting the administration of Kayexalate and sorbitol. Options A, B, and D have either potassium levels within normal limits, which would not necessitate this aggressive treatment, or potassium levels that are lower than what would typically prompt the need for Kayexalate and sorbitol.
3. A woman with an anxiety disorder calls her obstetrician's office and tells the nurse of increased anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her antianxiety medications, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman?
- A. Describe the transmission of drugs to the infant through breast milk
- B. Encourage her to use stress-relieving alternatives, such as deep breathing exercises
- C. Inform her that some antianxiety medications are safe to take while breastfeeding
- D. Explain that anxiety is a normal response for the mother of a 3-week-old.
Correct answer: C
Rationale: There are several antianxiety medications that are not contraindicated for breastfeeding mothers, so it is important to inform her of this option.
4. A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. What intervention is best for the RN to implement?
- A. Isolate the client from the other clients.
- B. Administer a PRN sedative.
- C. Avoid recognizing the behavior.
- D. Escort the client to his room.
Correct answer: C
Rationale: The correct intervention for the RN to implement in this situation is to avoid recognizing the behavior. By not reinforcing the echolalia through recognition, the behavior is less likely to be perpetuated, and it can reduce annoyance to other clients on the unit. Isolating the client may lead to feelings of rejection and exacerbate the behavior. Administering a PRN sedative should not be the first line of intervention for echolalia, as it does not address the underlying cause. Escorting the client to his room does not actively address the behavior or provide a therapeutic response.
5. A female client’s significant other has been at her bedside providing reassurances and support for the past 3 days, as desired by the client. The client’s estranged husband arrives and demands that the significant other not be allowed to visit or be given condition updates. Which intervention should the nurse implement?
- A. Obtain a prescription from the healthcare provider regarding visitation privileges
- B. Request a consultation with the ethics committee for resolution of the situation
- C. Encourage the client to speak with her husband regarding his disruptive behavior
- D. Communicate the client’s wishes to all members of the multidisciplinary team
Correct answer: B
Rationale: In a situation where a client's estranged husband demands to restrict the visitation of the significant other, it is essential to prioritize the client's wishes while addressing the conflict. Requesting a consultation with the ethics committee is appropriate as it allows for a comprehensive and impartial resolution, ensuring the client's autonomy and well-being are upheld. Option A is incorrect because visitation privileges are not solely determined by a healthcare provider's prescription in this scenario. Option C may not be appropriate as it puts the client in a potentially uncomfortable or unsafe position. Option D, while important, does not directly address the conflict between the estranged husband and the significant other.