HESI RN
RN HESI Mental Health with NGN Questions
Extract:
Question 1 of 5
A homeless male who was found sitting in the middle of a busy street is brought to the emergency department (ED). On admission, the client is confused and has difficulty answering questions. After ruling out a physiological etiology for the client's behavior, he is transferred to the mental health unit. When admitting the client to the unit, which action is most important for the nurse to take?
Correct Answer: B
Rationale: Performing a mental status exam is critical to assess the client's consciousness, orientation, and thought processes, identifying potential mental disorders.
Question 2 of 5
A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words, and wanders into client's rooms. The nurse decides that the client needs constant observation based on which of these assessment findings?
Correct Answer: C
Rationale: Wandering into clients' rooms poses a safety risk to the client and others, necessitating constant observation.
Question 3 of 5
The nurse is completing the admission assessment of an adolescent client who is underweight and admitted to a psychiatric unit with a diagnosis of depression. Which finding requires notification to the healthcare provider?
Correct Answer: C
Rationale: A potassium level of 2.9 mEq/dL is below normal, indicating hypokalemia, which can cause cardiac and neuromuscular issues, requiring immediate notification.
Question 4 of 5
A client with a history of anxiety and depression presents to the emergency department with a headache, nausea, and vomiting. The client's vital signs are temperature 100.9°F (38.3°C), heart rate 115 beats/minute, respirations 21 breaths/minute, and blood pressure 216/108 mm Hg. When reviewing the client's medications, which information is of most concern to the nurse?
Correct Answer: B
Rationale: Phenelzine, an MAOI, can cause a hypertensive crisis when combined with tyramine-containing foods or certain medications, which aligns with the client's elevated blood pressure.
Question 5 of 5
A client is admitted to the emergency department because of a possible overdose of methadone and benzodiazepines. The admission respiratory rate is 6 breaths/minute. Based on this finding, the nurse should prepare for which intervention?
Correct Answer: D
Rationale: Naloxone is the priority to reverse opioid-induced respiratory depression from methadone overdose, addressing the critical respiratory rate of 6 breaths/minute.