HESI RN
RN HESI Mental Health with NGN Questions
Extract:
Question 1 of 5
The nurse is planning the care for a client who is hospitalized with a bipolar disorder. The client wanders the hallways, talks excessively, and makes sexual comments about the staff. Which intervention(s) should the nurse include in the plan of care? Select all that apply.
Correct Answer: A,C,D
Rationale: Giving concise and firm directions for hygiene and dressing helps provide structure and support during periods of manic behavior. Assigning the client to a single room provides a quieter and less stimulating environment, promoting a more controlled and therapeutic setting. Inviting the client for a walk when their energy is high allows for a structured outlet for excess energy and may help with symptom management.
Question 2 of 5
A client who has been taking clozapine reports experiencing a sore throat and has a temperature of 101.9° F (38.8° C). Which action should the nurse take?
Correct Answer: B
Rationale: Obtaining a CBC is critical to assess for clozapine-induced agranulocytosis, a life-threatening side effect, given the sore throat and fever.
Question 3 of 5
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?
Correct Answer: A
Rationale: Ineffective breathing pattern is the highest priority, as aspiration of caustic material can lead to respiratory compromise, requiring immediate attention.
Question 4 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.
Question 5 of 5
A client who experiences memory loss is diagnosed with Wernicke encephalopathy caused by alcohol addiction. Which intervention is most important for the nurse to implement?
Correct Answer: C
Rationale: Thiamine administration is critical for Wernicke encephalopathy to address thiamine deficiency, a key factor in this condition.