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MENTAL HESI V1 2021.
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Stuvia.com - The Marketplace to Buy and Sell your Study MaterialMENTAL HESI V1 2021
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HESI
1-A 6-year-old girl with severe birth defects who is mentally disabled is brought to
the emergency room because of a broken arm. The caregiver reports that the girl
sustained the injury when she fell from her wheelchair. Which intervention is
most important for the nurse to implement?
Evaluate the child for other injuries.
Rationale: Because a 6-year-old child with low level fall that results in a fracture should
be considered a possible victim of child abuse, until proven otherwise.
2-The community health nurse facilitates a substance abuse prevention group for
a homeless population. Which statement demonstrates that a client has a realistic
understanding of the recovery process?
"By learning what led to my latest relapse, I know what to do in the future."
Rationale: Recovery is a lifelong process in which clients must constantly learn and
apply new behaviors to replace ineffective ones. Every attempt toward recovery
improves long-term chances of success, so those who learn from their relapses
demonstrate an understanding of the process.
3-A woman admitted to the Emergency Department is bleeding profusely from a
patch where her hair was lost from her scalp. She is accompanying by her
husband who tells the nurse that his wife caught her hair on the railing and pulled
it out when she fell down the stairs. The husband is solicitous of his wife and
quickly answers questions on her behalf. He attempts to comfort his wife by
saying to her, "I am right here with you, dear. Nothing can keep us apart." What is
the priority nursing intervention?
Require the husband to leave the cubicle while the client is being treated.
Rationale: This client should be questioned about the possibility of spousal abuse and
cannot answer truthfully in the presence of the perpetrator, so separating the couple is a
priority.
4-While assessing a 70-year old male client, a nurse working in the outpatient
clinic notices bruises on the client's chest. The client admits that his daughter,
who is his caregiver, becomes frustrated and sometimes hits him. What is the
priority outcome for the elderly client who sustained the abuse?
Expresses his feelings of satisfaction with care.
Rationale: Abuse cessation should result in the client feeling satisfied with his care.
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5-The nurse is assessing a client who is believed to have a borderline personality
disorder. Which question is most important to include in this assessment?
"Do you frequently have temper tantrums?"
Rationale: Those with a borderline personality disorder demonstrate intense outbursts
of anger.
6-A nurse is teaching a female client who is in a homosexual relationship about
women's health. Which topic is the most important for the nurse to address?
Domestic violence interventions.
Rationale: Since all women, regardless of sexual orientation, are at risk for domestic
violence that can be potentially lethal, this is the most important topic for the nurse to
address.
7-A client who abuses alcohol says to the nurse, "I am glad I went in for
treatment. Now my problems with alcohol are all behind me." Which response is
best for the nurse to provide?
"Can you tell me more about what you mean when you say that your problems with
alcohol are now behind you?"
Rationale: Those who attend alcohol treatment programs and Alcoholics Anonymous
never put drinking problems behind them and describe alcoholics as only one step away
from a slip with maintaining sobriety. The nurse should use reflection and encourage the
client to further describe his feelings.
8-A male client who is on the liver transplant list is called to the unit for a possible
transplant. When learning that the donor organ is no longer available, the client
slams doors and shouts vulgarities about his situation. What action should the
nurse implement first?
Express concern over his disappointment.
Rationale: Addressing the client's disappointment enables the client to express feelings
of frustration in a safe environment.
9-A client is told that her infant will be stillborn. What is the most important action
for the nurse to implement after the birth?
Ask the family if they would like to see and hold the infant after birth.
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