HESI RN
RN Hesi Mental Health Questions
Extract:
Laboratory Test
Result
Glucose
75 mg/dL (4.2 mmol/L)
Reference Range
74 to 106 mg/dim (4.1 to 5.9 mmol/L)
Question 1 of 5
Click to highlight the assessment findings that require IMMEDIATE follow-up by the nurse. The client is a 68-year-old with a history of diabetes, hypertension (HTN), coronary artery disease (CAD), and recently diagnosed with end-stage renal disease (ERSD). She has been on hemodialysis three times a week for one month and presents to the emergency department (ED) with: Fatigue, Generalized weakness, Muscle cramps, Tingling sensation in her arms and legs, Lightheadedness. She also reports having missed her scheduled dialysis for the past 2 days, coupled with complaints of nausea, poor appetite, and an inability to attend the dialysis sessions.
Correct Answer: A,B,C
Rationale: Muscle cramps, tingling sensation, and lightheadedness are signs of electrolyte imbalance, likely due to missed dialysis, which can lead to serious complications like cardiac arrhythmias. The nurse should monitor vital signs, neurological status, and notify the physician.
Extract:
Question 2 of 5
A female client with bulimia is admitted to the mental health unit after she disclosed to a friend that she purges after meals. Which intervention should the nurse implement first?
Correct Answer: B
Rationale: Assessing weight, vital signs, and electrolytes is critical to identify life-threatening complications of bulimia, taking precedence over other interventions.
Extract:
History and Physical
Initial vital signs:
Imaging Studies
The client is a 68-year-old with a history of diabetes, hypertension (HTN), coronary artery disease (CAD), and was recently diagnosed with end-stage renal disease (ERSD).
She has been placed on hemodialysis three times a week for one month. She presents to the emergency department (ED) with fatigue, generalized weakness, muscle cramps, tingling sensation in arms and legs, and lightheadedness following 3 days of illness during which her husband reports she has complained of nausea and had a poor appetite and not able to go for her scheduled dialysis.
Question 3 of 5
The nurse determines the plan of care. For each action, click to indicate whether they would be included or not included in the plan of care for the client.
| Options | Included | Not Included |
|---|---|---|
| Monitor cardiac status | ||
| Educate on dialysis compliance | ||
| Monitor vital signs | ||
| Perform head-to-toe assessment | ||
| Monitor heart rhythm | ||
| Monitor fluid intake and output | ||
| Monitor neuromuscular status |
Correct Answer: A,B,C,D,E,F,G
Rationale: Monitoring cardiac status, vital signs, heart rhythm, fluid balance, and neuromuscular status, along with educating on dialysis compliance and low-potassium diet, are essential for managing ESRD and hyperkalemia. Transfer to telemetry is not indicated with stable vitals.
Extract:
Question 4 of 5
The nurse is developing a plan of care for an older client with hypertension who reports chest pain on exertion. Which outcome should the nurse include in the plan of care for this client?
Correct Answer: D
Rationale: Recording episodes of angina and self-management for one week is a specific and appropriate outcome to monitor the client's chest pain and response to interventions. Weekly monitoring, daily walking, and nitroglycerine use are important but do not directly address tracking angina episodes for management.
Extract:
History and Physical
Laboratory Results
Vital signs
The client is a 68-year-old with a history of diabetes, hypertension (HTN), coronary artery disease (CAD), and was recently diagnosed with end-stage renal disease (ERSD). She has been placed on hemodialysis three times a week for one month. She presents to the emergency department (ED) with fatigue, generalized weakness, muscle cramps, tingling sensation in her arms and legs, and lightheadedness following 3 days of Illness during which her husband reports she has complained of nausea and had a poor appetite and not able to go for her scheduled dialysis 2
On further assessment, the client reports that her doctor had recently started her on Lisinopril for blood pressure control but it "doesn't seem to help". She then complained of some chest discomfort. The client is moved to an ED room, and another set of vital signs is performed. Physician notified and orders received
Question 5 of 5
Which of the following physician's orders requires priority attention from the nurse? Select all that apply.
Correct Answer: E,F
Rationale: Chest X-ray and continuous cardiac monitoring are priorities to assess chest discomfort and potential arrhythmias in a client with CAD and hyperkalemia risk. Other orders are important but less urgent.