HESI RN
Mental Health HESI
1. What assessment questions should the nurse ask when attempting to determine a teenager’s mental health resilience? Select all that apply.
- A. How did you cope when your father deployed with the Army for a year in Iraq?
- B. Who did you go to for advice while your father was away for a year in Iraq?
- C. How do you feel about talking to a mental health counselor?
- D. Where do you see yourself in 10 years?
Correct answer: C
Rationale: The question 'How do you feel about talking to a mental health counselor?' is the most appropriate to assess the teenager's mental health resilience as it directly addresses their willingness to seek help and cope effectively. Choices A and B focus on coping mechanisms during a specific event, which may not reflect the teenager's overall resilience. Choice D is more related to future aspirations rather than assessing current mental health resilience.
2. A client is being educated by a healthcare professional about initiating a prescribed abstinence therapy using Disulfiram (Antabuse). What information should the client acknowledge understanding?
- A. Admit to others that they are a substance abuser.
- B. Remain alcohol-free for 12 hours before taking the first dose.
- C. Attend monthly Alcoholics Anonymous meetings.
- D. Completely abstain from heroin or cocaine use.
Correct answer: B
Rationale: B: Before starting Disulfiram therapy, it is crucial for clients to be alcohol-free for a minimum of 12 hours to prevent adverse reactions. A: Admitting substance abuse is important, but it is not directly linked to the initiation of Disulfiram therapy. C: Attending Alcoholics Anonymous meetings is beneficial for support but not a specific requirement for starting Disulfiram. D: The focus of Disulfiram therapy is on alcohol abstinence, so abstaining from heroin or cocaine is not directly related to this medication.
3. 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.
4. A male client with bipolar disorder tells the nurse that he needs to 'make some deals so that he can improve his retirement savings.' Based on this information, which client outcome should the nurse include in the plan of care?
- A. Delay business decisions until his mania subsides.
- B. Identify the feelings associated with his behaviors.
- C. Seek legal counsel when making business decisions.
- D. Describe why he is feeling fearful about his finances.
Correct answer: A
Rationale: In individuals with bipolar disorder experiencing mania, impulsivity and poor judgment are common. Delaying business decisions until the mania subsides is crucial to prevent impulsive and potentially harmful financial choices. Choice B, identifying feelings associated with behaviors, may be important but does not directly address the immediate need to prevent risky financial decisions. Seeking legal counsel (Choice C) may be appropriate in some situations but is not the priority in managing acute mania. Describing why he feels fearful about finances (Choice D) is relevant for understanding emotions but does not address the immediate risk of impulsive financial actions during mania.
5. A client with anorexia nervosa has a body mass index (BMI) of 16.5 and has been diagnosed with bradycardia. Which of the following findings should the RN be most concerned about?
- A. Body temperature of 96.8°F.
- B. Heart rate of 52 BPM.
- C. Serum potassium level of 4.1 mEq/L.
- D. Electrocardiogram (ECG) changes.
Correct answer: D
Rationale: In a client with anorexia nervosa and bradycardia, monitoring for ECG changes is crucial as these changes may indicate potentially life-threatening cardiac complications. While other findings like low body temperature, bradycardia, and serum potassium levels are concerning, ECG changes specifically reflect the impact of bradycardia on the heart's electrical activity and should be the priority for the nurse to assess and address.
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