HESI LPN
HESI CAT Exam 2024
1. An older male was recently admitted to the rehabilitation unit with unilateral neglect syndrome as a result of a cerebrovascular accident (CVA). Which action should the nurse include in the plan of care?
- A. Provide additional light in the room to promote sensory stimulation
- B. Teach the client to turn his head from side to side for visual scanning
- C. Place a clock and calendar in the room to improve orientation
- D. Use hand and arm gestures to improve communication and comprehension
Correct answer: B
Rationale: Teaching the client to turn his head from side to side for visual scanning is essential in addressing unilateral neglect syndrome caused by a cerebrovascular accident. This action helps improve visual awareness and assists the client in overcoming the neglect of one side of the body. Providing additional light for sensory stimulation (Choice A) may not directly address the issue of unilateral neglect. Placing a clock and calendar in the room (Choice C) may be helpful for orientation but does not specifically target unilateral neglect. Using hand and arm gestures for communication (Choice D) may aid in communication but does not directly address the visual scanning deficits associated with unilateral neglect syndrome.
2. A client in the intensive care unit is being mechanically ventilated, has an indwelling urinary catheter in place, and is exhibiting signs of restlessness. Which action should the nurse take first?
- A. Review the heart rhythm on cardiac monitors
- B. Check urinary catheter for obstruction
- C. Auscultate bilateral breath sounds
- D. Give PRN dose of lorazepam (Ativan)
Correct answer: B
Rationale: When a client in the intensive care unit is mechanically ventilated, has an indwelling urinary catheter, and is restless, the priority action is to check the urinary catheter for obstruction. Restlessness in this context could be due to a blocked catheter causing discomfort or urinary retention, which needs immediate attention to prevent complications. Reviewing the heart rhythm on cardiac monitors can be important but is not the priority in this scenario. Auscultating bilateral breath sounds is also important in a ventilated client but addressing the potential immediate issue of a blocked catheter takes precedence. Giving a PRN dose of lorazepam should not be the first action without addressing the underlying cause of restlessness.
3. An older male client with a history of type 1 diabetes has not felt well for the past few days and arrives at the clinic with abdominal cramping and vomiting. He is lethargic, moderately confused, and cannot remember when he took his last dose of insulin or ate last. What action should the nurse implement first?
- A. obtain a serum potassium level
- B. administer the client's usual dose of insulin
- C. assess pupillary response to light
- D. Start an intravenous (IV) infusion of normal saline
Correct answer: D
Rationale: Administering IV fluids is crucial to address potential dehydration and electrolyte imbalances, especially if the client is unable to provide a clear history. Starting an IV infusion of normal saline will help rehydrate the client and address any electrolyte imbalances, which are common in clients with diabetes experiencing symptoms like abdominal cramping and vomiting. Obtaining a serum potassium level can be important but is not the priority when the client is showing signs of dehydration and confusion. Administering insulin should only be done after addressing hydration and electrolyte status. Assessing pupillary response to light is not the most critical action in this situation compared to addressing dehydration and potential electrolyte imbalances.
4. A male client, admitted to the mental health unit for a somatoform disorder, becomes angry because he cannot have his pain medication. He demands that the nurse call the healthcare provider and threatens to leave the hospital. What action should the nurse take?
- A. Place the client in seclusion per unit guidelines
- B. Administer a PRN prescription for lorazepam (Ativan)
- C. Call security to help ensure staff and client safety
- D. Ask what other methods he uses to deal with pain
Correct answer: C
Rationale: In this scenario, the nurse should prioritize ensuring safety. When a client becomes aggressive and threatens to leave, calling security is crucial to help maintain a safe environment for both staff and the client. Placing the client in seclusion (choice A) is not the appropriate initial action as it may escalate the situation further. Administering lorazepam (choice B) should not be the first response to behavioral issues. Asking about other pain management methods (choice D) is not the immediate priority when safety is at risk.
5. After witnessing a preoperative client sign the surgical consent form, what are the legal implications of the nurse's signature on the client's form as a witness?
- A. The client voluntarily grants permission for the procedure to be done
- B. The surgeon has explained to the client why the surgery is necessary
- C. The client is competent to sign the consent without impairment of judgment
- D. The client understands the risks and benefits associated with the procedure
Correct answer: C
Rationale: The nurse's signature on the consent form signifies that the client is competent to sign the consent without impairment of judgment. This legal implication ensures that the client possesses the necessary capacity to make decisions about their healthcare. Choice A is incorrect because the nurse's signature does not imply the client's voluntary permission for the procedure. Choice B is incorrect as it pertains to the surgeon's responsibility, not the nurse's. Choice D is incorrect as the nurse's signature does not confirm the client's understanding of the risks and benefits associated with the procedure.
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