HESI LPN
HESI PN Exit Exam 2023
1. The client with schizophrenia who continues to repeat the last words heard is exhibiting a sign of disturbed thought processes. Which nursing problem should the nurse document in the medical record?
- A. Altered sensory perception
- B. Impaired social interaction
- C. Risk for self-directed violence
- D. Disturbed thought processes
Correct answer: D
Rationale: The correct answer is D: Disturbed thought processes. Echolalia, the repetition of words, is a sign of disturbed thought processes commonly seen in clients with schizophrenia. It reflects a disorganization in thinking rather than a sensory perception issue (Choice A). Impaired social interaction (Choice B) refers to difficulties in relating to others, which is not the primary concern in echolalia. Risk for self-directed violence (Choice C) focuses on potential harm to self, which is separate from the repetitive behavior of echolalia.
2. The nurse is teaching a client with diabetes mellitus how to differentiate between hypoglycemia and ketoacidosis. What statement indicates to the nurse that the client has an understanding of this condition?
- A. Glucose should be taken if I have a fruity breath odor.
- B. Glucose should be taken if I am urinating more than usual.
- C. Glucose should be taken if I have blurred vision.
- D. Glucose should be taken if I develop shakiness.
Correct answer: D
Rationale: The correct answer is D. Shakiness is a symptom of hypoglycemia, which is low blood sugar. Taking glucose can help raise blood sugar levels quickly in this situation. Fruity breath odor and excessive urination are signs of ketoacidosis, a complication of diabetes involving high levels of ketones in the blood. Blurred vision can be a symptom of high blood sugar, but it is not specific to hypoglycemia.
3. A client is post-operative day one following an open cholecystectomy. The nurse notices the client's drainage from the T-tube is dark green. What is the most appropriate action for the nurse to take?
- A. Document the finding as normal.
- B. Notify the healthcare provider immediately.
- C. Decrease the suction on the T-tube.
- D. Flush the T-tube with saline to ensure patency.
Correct answer: A
Rationale: Dark green drainage from a T-tube after a cholecystectomy is bile, which is an expected finding. Bile is normally dark green in color. It is important for the nurse to recognize this as a normal post-operative occurrence and document the finding. There is no need to notify the healthcare provider immediately as this finding is an anticipated part of the client's recovery. Decreasing the suction on the T-tube or flushing it with saline is unnecessary and may not be indicated based on the color of the drainage. Therefore, the most appropriate action for the nurse to take is to document the dark green drainage as a normal finding.
4. Which vitamin deficiency is most associated with night blindness?
- A. Vitamin A
- B. Vitamin B12
- C. Vitamin C
- D. Vitamin D
Correct answer: A
Rationale: The correct answer is Vitamin A. Vitamin A deficiency leads to night blindness because this vitamin is crucial for the formation of rhodopsin, a photopigment in the retina. Rhodopsin is essential for vision in low-light conditions. Vitamin B12 deficiency can lead to anemia and neurological issues but is not directly related to night blindness. Vitamin C deficiency can cause scurvy, affecting connective tissues, but not night vision. Vitamin D deficiency can lead to bone disorders but is not primarily associated with night blindness.
5. The home health nurse suspects elder abuse after observing fresh lacerations on the arms and legs of an older adult male client who lives with his daughter. Which action is most important for the nurse to take?
- A. Document the lacerations in the client's record
- B. Report findings to the supervisor for referral to adult protective services
- C. Ask the daughter who has been taking care of the client on a daily basis
- D. Apply dry dressings after cleansing the wounds
Correct answer: B
Rationale: In cases where elder abuse is suspected, the most critical action for the nurse to take is to report the findings to the supervisor for referral to adult protective services. This step is essential to protect the client from further harm and ensure their safety. Documenting the lacerations, as suggested in choice A, is important but not as urgent as ensuring immediate intervention by reporting the abuse. Asking the daughter for information, as in choice C, may not be effective if she is the abuser. Applying dressings, as in choice D, is a lower priority compared to taking action to address the suspected abuse.
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