HESI LPN
HESI CAT Exam Test Bank
1. 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.
2. The nurse is assessing an older adult with type 2 diabetes. Which assessment finding indicates that the client understands long-term control of diabetes?
- A. The fasting blood sugar was 120 mg/dL this morning
- B. Urine ketones have been negative for the past 6 months
- C. The hemoglobin A1C was 6.5% last week
- D. No diabetic ketoacidosis has occurred in 6 months
Correct answer: C
Rationale: An A1C level of 6.5% indicates good long-term control of diabetes as it reflects the average blood sugar levels over the past 2-3 months. Monitoring fasting blood sugar provides immediate information about the current blood sugar level, while the absence of urine ketones indicates short-term control. Although the absence of diabetic ketoacidosis is positive, it doesn't specifically reflect long-term control like the A1C level does.
3. An adolescent male client is admitted to the hospital. Based on Erikson’s theory of psychosocial development, which nursing intervention best assists this adolescent’s adjustment to his hospital stay?
- A. Invite him to participate in the evening group activity
- B. Schedule frequent private phone calls to his parents
- C. Provide access to a variety of video games in his room
- D. Encourage him to learn his way around the hospital
Correct answer: A
Rationale: Inviting the adolescent to participate in group activities aligns with Erikson's theory of psychosocial development, specifically the stage of developing social relationships. By engaging in group activities, the adolescent can interact with peers, fostering social skills and aiding in adjustment to the hospital environment. Choice B is incorrect as excessive reliance on phone calls to parents may hinder the adolescent's autonomy and independence, which are crucial aspects of Erikson's theory for this age group. Choice C, providing access to video games, while potentially offering entertainment, does not directly address the need for social interaction and relationship-building. Choice D, encouraging the adolescent to learn his way around the hospital, is important for familiarity but may not directly address the need for social interaction and adjustment in the hospital setting.
4. When administering diazepam, a benzodiazepine, 10 mg IV push PRN for a client with alcohol withdrawal symptoms, which actions should the nurse implement? (Select all that apply)
- A. Protect the medication from light exposure
- B. Monitor for changes in level of consciousness
- C. Observe for onset of generalized bruising or bleeding
- D. Perform ongoing assessment of respiratory status
Correct answer: D
Rationale: When administering diazepam for a client with alcohol withdrawal symptoms, it is crucial to perform ongoing assessment of respiratory status. Diazepam can lead to respiratory depression, emphasizing the need for continuous monitoring to detect any signs of respiratory distress early. Protecting the medication from light exposure is a general guideline for some drugs but is not a specific concern for diazepam. Observing for bruising or bleeding is not directly associated with the administration of diazepam for alcohol withdrawal symptoms, making choices A and C incorrect.
5. When assessing a client's blood pressure and determining an auscultatory gap, which action should the nurse implement?
- A. Compare the palpated systolic blood pressure with the auscultated pressure
- B. Assess the client for lightheadedness upon standing
- C. Determine if an automated blood pressure reading is consistent with the manual reading
- D. Observe for changes in blood pressure between lying and sitting positions
Correct answer: A
Rationale: When an auscultatory gap is present, comparing the palpated systolic blood pressure with the auscultated pressure is crucial. This helps to accurately measure blood pressure and detect any discrepancies caused by the gap. Assessing for lightheadedness upon standing (choice B) is unrelated to addressing an auscultatory gap. Checking the consistency between automated and manual blood pressure readings (choice C) is important for validation but not specifically for managing an auscultatory gap. Observing blood pressure changes between lying and sitting positions (choice D) is relevant for orthostatic hypotension assessment but not for dealing with an auscultatory gap.
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