HESI LPN
Mental Health HESI 2023
1. Which client outcome indicates improvement for a client who is admitted with auditory hallucinations?
- A. Argues with the voices.
- B. Tells when voices decrease.
- C. Follows what the voices say.
- D. Tells the nurse what the voices say.
Correct answer: B
Rationale: The correct answer is B: 'Tells when voices decrease.' This outcome indicates improvement because it shows that the client is experiencing a reduction in auditory hallucinations. By communicating that the voices are decreasing, it suggests that the client's symptoms are improving and the treatment is effective. Choices A, C, and D are incorrect. Arguing with the voices (A) indicates ongoing engagement with the hallucinations, which is not a positive outcome. Following what the voices say (C) suggests compliance with the hallucinations, which is not indicative of improvement. Lastly, telling the nurse what the voices say (D) does not necessarily demonstrate a reduction in hallucinations or improvement in the client's condition.
2. A nurse receives a report about a client receiving IV fluids infusing at 125 mL/hr but notes they have only received 80 mL over the last 2 hours. What should the nurse do first?
- A. Check IV tubing for obstruction
- B. Increase the flow rate
- C. Change the IV site
- D. Notify the physician
Correct answer: A
Rationale: The correct first action for the nurse to take is to check the IV tubing for obstruction. This step is crucial in ensuring that the IV fluids are flowing properly and that there are no blockages preventing the correct infusion rate. Increasing the flow rate (Choice B) without confirming the tubing's status could lead to potential complications if there is indeed an obstruction. Changing the IV site (Choice C) is not the priority in this situation unless there are specific clinical indications. Notifying the physician (Choice D) can be done after checking the tubing for obstruction, as the physician may need to be informed depending on the findings.
3. When an increase in exercise is accompanied by a decrease in body weight, it is an example of what?
- A. variable effect
- B. positive correlation
- C. negative correlation
- D. randomization effect
Correct answer: C
Rationale: When an increase in exercise is accompanied by a decrease in body weight, it demonstrates a negative correlation. This means that as one variable (exercise) increases, the other variable (body weight) decreases. Choice A, 'variable effect,' is vague and does not accurately describe the relationship between exercise and body weight. Choice B, 'positive correlation,' is incorrect because in a positive correlation, both variables would increase or decrease together. Choice D, 'randomization effect,' is unrelated to the scenario described.
4. At 0100 on a male client's second postoperative night, the client states he is unable to sleep and plans to read until feeling sleepy. What action should the nurse implement?
- A. Stay with the client and offer assistance with relaxation techniques
- B. Assess the client's pain level and administer pain medication if needed
- C. Bring the client a prescribed PRN sedative-hypnotic
- D. Encourage the client to engage in a quiet, non-stimulating activity until feeling sleepy
Correct answer: C
Rationale: At 0100 on the client's second postoperative night, the nurse should address the client's inability to sleep. Providing a prescribed PRN sedative-hypnotic is appropriate in this situation to help the client rest. Choice A is incorrect because leaving the room and closing the door does not directly address the client's sleep concern. Choice B is not the priority at this moment since the client's main issue is insomnia, not pain. Choice D, while encouraging a non-stimulating activity, does not provide immediate relief for the client's sleeplessness as a sedative-hypnotic would.
5. A client with myasthenia gravis (MG) is receiving immunosuppressive therapy. Review of recent laboratory test results shows that the client’s serum magnesium level has decreased below the normal range. In addition to contacting the healthcare provider, what nursing action is most important?
- A. Check the visual difficulties
- B. Note the most recent hemoglobin level
- C. Assess for hand and joint pain
- D. Observe rhythm on telemetry monitor
Correct answer: D
Rationale: The correct answer is to observe the rhythm on the telemetry monitor. Decreased magnesium levels can lead to cardiac issues, such as arrhythmias. Monitoring the heart rhythm is crucial in this situation. Checking visual difficulties (choice A) is not directly related to the potential cardiac effects of low magnesium levels. Noting the hemoglobin level (choice B) and assessing for hand and joint pain (choice C) are not the priority when dealing with low magnesium levels and possible cardiac complications.