HESI RN
RN Hesi Mental Health Questions
Extract:
Question 1 of 5
The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?
Correct Answer: C
Rationale: Close monitoring and intervention are critical to prevent self-harm in a client showing signs of distress, prioritizing safety.
Question 2 of 5
A female client engages in repeated checks of door and window locks and behavior that prevents her from arriving on time and interfering with her ability to function effectively. Which action should the nurse take?
Correct Answer: D
Rationale: Planning daily activities redirects focus from compulsive checking, reducing anxiety and improving function, suitable for OCD-like behaviors.
Extract:
History and Physical
Initial 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 arms and legs, and lightheadedness following 3 days of illness during which her husband reports she has complained of nausea and had poor appetite and was not able to go for her scheduled dialysis 2
Question 3 of 5
Based on the client's subjective and objectives data, the nurse recognizes that she is having signs and symptoms of a sinus tachycardiahyperkalemiahypermagnesemiahypokalemia.
| Sinus tachycardia |
| Hyperkalemia |
| Hypermagnesemia |
| Hypokalemia |
Correct Answer: B
Rationale: The client's history of ESRD, missed dialysis, and symptoms (muscle cramps, tingling, weakness) suggest hyperkalemia, which can cause cardiac arrhythmias like sinus tachycardia. Other options are less consistent with the clinical picture.
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 4 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.
| Muscle cramps |
| Tingling sensation in her arms and legs |
| Lightheadedness |
| Fatigue |
| Generalized weakness |
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 5 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.