Rn Hesi Mental Health
Rn Hesi Mental Health ( 38 Questions)
Patient Data
History and Physical Laboratory Results
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.
Laboratory Test
Glucose Result
75 mg/dL (4.2 mmol/L)
Reference Range
74 to 106 mg/dL (4.1 to 5.9 mmol/L)
Nurses' Notes
Flow Sheet Orders
Imaging Studies
12 lead EKG
. CBC
Basic metabolic panel
. Chest X-ray
. Place on a continuous cardiac monitor
. CT scan of abdomen Blood cultures times 2 sets
- Echocardiogram
Initial vital signs: BP 146/82 mm Hg, heart rate 114 beats/minute, respiratory rate 18 breaths/minute, Spo, 98% on room air, temperature 98.2 °F (36.8 °C) orally.
Vital signs: BP 156/88 mm Hg, heart rate 116 beats/minute, respiratory rate 22 breaths/minute, Spo2 98% on room air, temperature 98.0 °F (36.7 °C) orally.
The client has been in IMU unit for 3 days and the physician plans to discharge her home today.
For each assessment finding, click to indicate whether the actions taken were effective or ineffective.
Each row must have only one response option selected.
Client Findings
Choice A rationale:
This finding suggests that the client may not be fully disclosing her symptoms or may not be aware of their significance. It should be investigated further.
Choice B rationale:
The blood pressure and heart rate are within an acceptable range, indicating that the client's blood pressure is relatively stable.
Choice C rationale:
A potassium level of 3.6 mEq/L falls within the reference range, indicating that the client's potassium level is within normal limits.
Choice D rationale:
The client's commitment to attending dialysis appointments is a positive sign, as regular dialysis is crucial for managing end-stage renal disease.
Choice E rationale:
If the client recognizes the need to resume her Lisinopril for blood pressure control, it indicates her understanding of the medication's importance in managing her hypertension.
Choice F rationale:
The client's willingness to incorporate nutrient-rich foods like dark green vegetables and potatoes into her diet is a positive sign for improving her nutritional status, which can be beneficial for her overall health. However, dietary changes should be discussed with her healthcare provider to ensure they are appropriate for her condition.
Choice A rationale:
This finding suggests that the client may not be fully disclosing her symptoms or may not be aware of their significance. It should be investigated further.
Choice B rationale:
The blood pressure and heart rate are within an acceptable range, indicating that the client's blood pressure is relatively stable.
Choice C rationale:
A potassium level of 3.6 mEq/L falls within the reference range, indicating that the client's potassium level is within normal limits.
Choice D rationale:
The client's commitment to attending dialysis appointments is a positive sign, as regular dialysis is crucial for managing end-stage renal disease.
Choice E rationale:
If the client recognizes the need to resume her Lisinopril for blood pressure control, it indicates her understanding of the medication's importance in managing her hypertension.
Choice F rationale:
The client's willingness to incorporate nutrient-rich foods like dark green vegetables and potatoes into her diet is a positive sign for improving her nutritional status, which can be beneficial for her overall health. However, dietary changes should be discussed with her healthcare provider to ensure they are appropriate for her condition.