HESI LPN
HESI CAT Exam Test Bank
1. The nurse is obtaining the medical histories of new clients at a community-based primary care clinic. Which individual has the highest risk for experiencing elder abuse?
- A. A 69-year-old widowed female who lives alone and volunteers at a school
- B. A 95-year-old ambulatory male who resides in a nursing home in a small town
- C. A 78-year-old female on a fixed income who lives with her relatives
- D. An 81-year-old male with diabetes who lives with his wife of 52 years
Correct answer: C
Rationale: Elder abuse risk is higher in individuals who live with relatives and are on a fixed income as these factors can contribute to vulnerability. Living with relatives may expose the individual to potential abusive situations within the family dynamics. Additionally, being on a fixed income may limit financial independence and increase dependency on others, potentially leading to financial abuse. The other options, such as living alone and volunteering, residing in a nursing home, or living with a long-term spouse, do not inherently pose the same level of risk factors for elder abuse as living with relatives on a fixed income.
2. The nurse is assigned to care for four surgical clients. After receiving report, which client should the nurse see first?
- A. An older client receiving packed RBCs on the third day postoperatively for colon resection
- B. An older client with continuous bladder irrigation who is 2 days postoperatively for bladder surgery
- C. An adult one day postoperatively from laparoscopic cholecystectomy requesting pain medication
- D. An adult in Buck’s traction, scheduled for hip arthroplasty within the next 12 hours
Correct answer: B
Rationale: The correct answer is B because the client with continuous bladder irrigation post-bladder surgery is at risk for complications like infection or bleeding. This client requires immediate attention to assess for any signs of complications such as urinary retention, hemorrhage, or infection. Choices A, C, and D have less urgent needs compared to a client with continuous bladder irrigation, which requires priority assessment.
3. A female client is admitted for a diabetic crisis resulting from inadequate dietary practices. After stabilization, the nurse talks to the client about her prescribed diet. What client characteristic is most important for successful adherence to the diabetic diet?
- A. Understands the importance of timing insulin administration 30 minutes before eating
- B. Frequently includes fruits and vegetables in meals and snacks
- C. Has access to someone who can assist with meal preparation and monitoring
- D. Demonstrates willingness to consistently follow the prescribed diet
Correct answer: D
Rationale: The most crucial characteristic for successful adherence to a diabetic diet is the client's willingness to consistently follow the prescribed diet plan. Option A, understanding insulin timing, is important for treatment but not directly related to dietary adherence. Option B, consuming fruits and vegetables, is a healthy practice but does not ensure adherence to a specific diabetic diet. Option C, having assistance with meal preparation, is beneficial but not as essential as the client's personal commitment to adhering to the diet consistently.
4. The charge nurse is making assignments for clients on an endocrine unit. Which client is best to assign to a new graduate nurse?
- A. A female adult with hyperthyroidism who is returning to the unit after a thyroidectomy
- B. A male adult with Cushing's syndrome who reports a headache and visual disturbances
- C. An older man with Addison's disease who is diaphoretic and has hand tremors
- D. A perimenopausal woman with Graves' disease who is nervous and has exophthalmos
Correct answer: A
Rationale: A new graduate nurse can manage the care of a stable client returning from a thyroidectomy. Choice B is not suitable for a new graduate nurse as it involves complex symptoms of Cushing's syndrome that require more experience and knowledge. Choice C presents a client with acute manifestations of Addison's disease, which may be challenging for a new graduate nurse. Choice D involves a client with Graves' disease experiencing nervousness and exophthalmos, which also require a higher level of expertise to manage effectively.
5. While teaching a young male adult to use an inhaler for his newly diagnosed asthma, the client stares into the distance and appears to be concentrating on something other than the lesson the nurse is presenting. What action should the nurse take?
- A. Remind the client of the importance of using a rescue inhaler for asthma management
- B. Leave the client alone to process his thoughts about the inhaler
- C. Ask the client what he is thinking about at that moment
- D. Pause and inquire if the client has any questions or needs clarification
Correct answer: C
Rationale: In this scenario, the most appropriate action for the nurse to take is to ask the client what he is thinking about at that moment. By doing so, the nurse can understand the client's concerns or distractions, which can then be addressed effectively during the teaching session. Option A is incorrect as it assumes the client is not paying attention due to forgetfulness about the importance of the inhaler, which may not be the case. Option B is incorrect because leaving the client alone without addressing the issue does not facilitate effective learning. Option D, although closer, does not directly address the client's distraction and may not uncover the underlying issue causing the lack of focus.
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