HESI RN
RN Hesi Mental Health Questions
Extract:
History and Physical
Laboratory Results
Imaging Studies
Initial vital signs
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.
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 1 of 5
Select the client actions that were effective in her treatment.
Correct Answer: B,C,D
Rationale: Stable BP/HR, normal potassium, and dialysis commitment indicate effective treatment. Denying symptoms needs investigation, resuming Lisinopril requires provider guidance, and high-potassium foods are inappropriate.
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 2 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 3 of 5
A client is admitted to the hospital with suicidal ideation. When completing the health history and admission assessment interview, which client comment is most important for the nurse to document?
Correct Answer: B
Rationale: Access to firearms is a significant risk factor for suicide, making it critical to document. Other comments are relevant but less urgent.
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.
Question 5 of 5
An adolescent client is admitted to the postoperative unit following open reduction of a fractured femur which occurred when the client fell down the stairs at a party. The nurse notices needle marks on the client's arms. Which assessment findings should the nurse document related to suspected narcotic withdrawal?
Correct Answer: B
Rationale: Agitation, sweating, and abdominal cramps are indicative of narcotic withdrawal, consistent with opioid use suggested by needle marks.