HESI RN
Mental Health HESI Quizlet Questions
Question 1 of 5
When changing the dressing for a client diagnosed with borderline personality disorder who has self-inflicted lacerations on the abdomen, which approach should the RN use?
Correct Answer: B
Rationale: The correct approach for the RN when changing the dressing for a client diagnosed with borderline personality disorder who has self-inflicted lacerations on the abdomen is to perform the dressing change in a non-judgmental manner. This approach helps maintain therapeutic rapport and respect for the client's situation. Choice A is incorrect because providing detailed and thorough explanations may not be as important as maintaining a non-judgmental attitude. Choice C is incorrect because asking why the client cut their own abdomen may come across as accusatory or threatening, which can be counterproductive in building trust. Choice D is incorrect because the RN should be equipped to handle the dressing change independently while ensuring a supportive and non-judgmental environment for the client.
Question 2 of 5
The RN on the evening shift receives a report that a client is scheduled for electroconvulsive treatment (ECT) in the morning. Which intervention should the RN implement the evening before the scheduled ECT?
Correct Answer: B
Rationale: Keeping the client NPO after midnight is the appropriate intervention before ECT to prevent complications during the procedure. Withholding food and fluids reduces the risk of aspiration and helps ensure the safety of the client. Option A (Hold all bedtime medications) is incorrect because medications may need to be given as prescribed unless specified otherwise by the healthcare provider. Option C (Implement elopement precautions) is unrelated to preparing a client for ECT and focuses on preventing a client from leaving the treatment area. Option D (Give the client an enema at bedtime) is unnecessary and not a standard pre-ECT preparation, making it an incorrect choice.
Question 3 of 5
A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and lack of motivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?
Correct Answer: B
Rationale: Teaching the client to develop a plan for daily structured activities is the most effective intervention in this scenario. This intervention helps address psychomotor retardation and enhances motivation and functioning. By structuring the client's day, it can provide a sense of purpose, routine, and accomplishment. Option A, providing education on methods to enhance sleep, may be helpful but does not directly address the client's overall functioning. Option C, suggesting the client develop a list of pleasurable activities, may provide temporary relief but may not address the core symptoms of major depressive disorder. Option D, encouraging the client to exercise, can be beneficial, but in this case, addressing the lack of structure and motivation through a daily plan is more appropriate.
Question 4 of 5
What is the most appropriate intervention by the RN to address a client with obsessive-compulsive disorder (OCD) who repeatedly checks to see if the door is locked and asks for reassurance?
Correct Answer: A
Rationale: Setting a specific limit on the checking behavior is the most appropriate intervention for a client with OCD who repeatedly checks the door and seeks reassurance. This approach helps the client gradually reduce the compulsive behavior, promotes independence, and supports progress in treatment. Choice B is not the most suitable intervention as it does not directly address the compulsive checking behavior. Choice C, providing consistent reassurance, may reinforce the compulsive behavior and hinder treatment progress. Choice D of ignoring the behavior does not actively assist the client in managing their symptoms and addressing the underlying disorder.
Question 5 of 5
A client who is admitted with a closed head injury after a fall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the nurse identify as the priority?
Correct Answer: A
Rationale: The correct answer is option A: Place in a side-lying position with the head of the bed elevated. This intervention is the priority because the client has a high blood alcohol level and is difficult to arouse, indicating potential risk for aspiration and airway compromise. Placing the client in a side-lying position helps prevent aspiration if vomiting occurs, and elevating the head of the bed can further reduce the risk of aspiration. Option B, administering disulfiram (Antabuse) immediately, is incorrect as it is used in the treatment of alcohol dependence to deter alcohol consumption by causing adverse reactions. However, in this acute situation, the priority is ensuring the client's safety and managing immediate risks. Option C, giving lorazepam (Ativan) PRN for signs of withdrawal, is also incorrect. While managing withdrawal symptoms is important, the priority in this case is addressing the client's compromised airway and potential for aspiration due to the high blood alcohol level. Option D, providing thiamine and folate supplements as prescribed, is important for clients with alcohol use disorder to prevent nutritional deficiencies. However, in the immediate post-admission period for a client with a high blood alcohol level and altered level of consciousness, airway management and safety take precedence over nutritional considerations. In the educational context, it is crucial for nurses to prioritize interventions based on the client's immediate needs and potential risks. Understanding the implications of high blood alcohol levels, altered consciousness, and the risk of aspiration guides nurses in providing safe and effective care for clients with substance use disorders and co-occurring conditions like closed head injuries.