HESI LPN
HESI Mental Health 2023
1. Which statement best demonstrates the nurse's role in ensuring that each client's rights are respected?
- A. Autonomy is a fundamental right for each client.
- B. Client rights are guaranteed by both state and federal laws.
- C. Being respectful and concerned will ensure attentiveness to clients' rights.
- D. Regardless of the client's condition, nurses must respect client rights.
Correct answer: C
Rationale: The statement 'Being respectful and concerned will ensure attentiveness to clients' rights' best demonstrates the nurse's role in ensuring that each client's rights are respected. This choice emphasizes the importance of being attentive and considerate towards clients to uphold their rights. Choice A is too general and lacks the direct connection to the nurse's role. Choice B highlights the legal aspect but does not specifically address the nurse's role. Choice D, although true, is not as comprehensive as choice C in describing the nurse's active role in respecting client rights.
2. A client with a history of chronic obstructive pulmonary disease (COPD) is prescribed oxygen therapy at 2 liters per minute via nasal cannula. What is the most important instruction the nurse should provide?
- A. Increase the oxygen flow rate if shortness of breath occurs
- B. Use oxygen only when experiencing shortness of breath
- C. Do not adjust the oxygen flow rate without consulting a healthcare provider
- D. Use a humidifier with the oxygen to prevent dry mucous membranes
Correct answer: C
Rationale: The most important instruction the nurse should provide to a client with COPD prescribed oxygen therapy is not to adjust the oxygen flow rate without consulting a healthcare provider. This is crucial because too much oxygen can suppress the client's respiratory drive, leading to further complications. Choice A is incorrect because increasing the oxygen flow rate without medical advice can be harmful. Choice B is incorrect as oxygen therapy should be used as prescribed, not just when symptoms occur. Choice D is incorrect as the priority is to ensure the correct oxygen flow rate rather than using a humidifier.
3. Which additional congenital malformation is expected in 80% of infants with a myelomeningocele?
- A. Cerebral palsy
- B. Hydrocephalus
- C. Meningitis
- D. Neuroblastoma
Correct answer: B
Rationale: Hydrocephalus is the additional congenital malformation expected in 80% of infants with a myelomeningocele. Myelomeningocele is commonly associated with hydrocephalus due to the abnormal accumulation of cerebrospinal fluid in the brain. Cerebral palsy (Choice A) is a motor disorder but not typically associated with myelomeningocele. Meningitis (Choice C) is an infection of the meninges and is not a congenital malformation. Neuroblastoma (Choice D) is a type of cancer that originates in immature nerve cells and is not a typical association with myelomeningocele.
4. The nurse assesses an adult male client 24 hours following abdominal surgery and finds that his blood pressure is 98/40 mm Hg, he is tachycardic, restless, and irritable. Which action should the nurse take first?
- A. Notify the healthcare provider of the findings.
- B. Ensure that the IV is infusing at the prescribed rate.
- C. Listen to lung sounds.
- D. Check under his back for evidence of bleeding.
Correct answer: D
Rationale: In this scenario, the nurse should first check under the client for evidence of bleeding. A blood pressure of 98/40 mm Hg, along with tachycardia, restlessness, and irritability, could indicate internal hemorrhage following abdominal surgery. Checking for bleeding under the back is crucial to rule out this life-threatening complication. Notifying the healthcare provider, ensuring IV infusion, or listening to lung sounds can be important but are secondary to ruling out immediate life-threatening conditions like internal bleeding.
5. Do neural tube defects cause an elevation in the alpha-fetoprotein (AFP) level in the mother’s blood?
- A. Yes
- B. No
- C. Possibly
- D. Never
Correct answer: A
Rationale: Yes, neural tube defects can cause an elevation in AFP levels in the mother’s blood. AFP levels are often used as a screening marker during pregnancy to detect neural tube defects. Choice B is incorrect because an elevation in AFP levels can indeed occur in the presence of neural tube defects. Choice C is not the best option as it leaves room for uncertainty when the relationship between neural tube defects and AFP elevation is well-established. Choice D is incorrect as neural tube defects are known to influence AFP levels in the maternal blood.