HESI LPN
Adult Health Exam 1
1. A client has a prescription for a Transcutaneous Electrical Nerve Stimulator (TENS) unit for pain management during the postoperative period following a Lumbar Laminectomy. What information should the nurse reinforce about the action of this adjuvant pain modality?
- A. Mild electrical stimulus on the skin surface closes the gates of nerve conduction for severe pain
- B. Pain perception in the cerebral cortex is dulled by the unit's discharge of an electrical stimulus
- C. An infusion of medication in the spinal canal will block pain perception
- D. The discharge of electricity will distract the client's focus on the pain
Correct answer: A
Rationale: The correct answer is A. TENS units work by delivering small electrical impulses through the skin. These impulses are thought to close the 'gates of nerve conduction,' which can help in managing severe pain. Choice B is incorrect because the dulled pain perception does not occur in the cerebral cortex by the TENS unit. Choice C is incorrect as it describes a different method of pain management involving medication in the spinal canal. Choice D is incorrect because TENS does not work by distracting the client's focus on pain, but rather by altering pain perception through electrical impulses.
2. A client is prescribed warfarin for the prevention of thromboembolism. What dietary instruction should the nurse provide?
- A. Increase intake of green leafy vegetables
- B. Maintain a consistent intake of vitamin K-rich foods
- C. Avoid all foods containing vitamin K
- D. Consume a high-protein diet
Correct answer: B
Rationale: The correct answer is B. Maintaining a consistent intake of vitamin K-rich foods is important for patients taking warfarin as it helps keep the effects of the medication stable. Choice A is incorrect because while green leafy vegetables are high in vitamin K, they should not be avoided completely but rather consumed consistently. Choice C is also incorrect as avoiding all foods containing vitamin K can lead to fluctuations in warfarin's effectiveness. Choice D is incorrect as a high-protein diet is not specifically recommended for patients taking warfarin.
3. A client reports feeling anxious and having trouble sleeping lately. What non-pharmacological intervention should the nurse suggest first?
- A. Starting an exercise program
- B. Keeping a sleep diary
- C. Practicing relaxation techniques before bed
- D. Using sleep-inducing medications at night
Correct answer: C
Rationale: The correct non-pharmacological intervention the nurse should suggest first for a client experiencing anxiety and sleep issues is practicing relaxation techniques before bed. Relaxation techniques like deep breathing, progressive muscle relaxation, or mindfulness meditation can help reduce anxiety levels and promote better sleep naturally. Starting an exercise program (Choice A) can be beneficial but may not provide immediate relief for anxiety and sleep problems. Keeping a sleep diary (Choice B) can help identify patterns but does not directly address anxiety. Using sleep-inducing medications (Choice D) should be considered only after non-pharmacological interventions have been tried.
4. What action should the nurse implement in caring for a client following an electroencephalogram (EEG)?
- A. Monitor the client's vital signs every 4 hours
- B. Assess the client's lower extremities for sensation
- C. Instruct the client to maintain bed rest
- D. Wash any paste from the client's hair and scalp
Correct answer: D
Rationale: The correct action the nurse should implement after an EEG is to wash any paste from the client's hair and scalp. This is crucial to prevent irritation and infection at the EEG site. Monitoring vital signs every 4 hours is not specifically indicated after an EEG. Assessing the client's lower extremities for sensation is unrelated to caring for a client post-EEG. While rest may be recommended after the procedure, there is no standard requirement for a specific duration of bed rest.
5. The nurse is caring for a client who has just returned from surgery with an indwelling urinary catheter in place. What is the most important assessment for the nurse to make?
- A. Check for catheter patency
- B. Assess the color of the urine
- C. Measure the urine output
- D. Ensure the catheter tubing is secure
Correct answer: C
Rationale: The most important assessment for the nurse to make in this situation is to measure the urine output. This assessment is crucial in monitoring kidney function and fluid balance after surgery. While checking for catheter patency is important, it is not as critical as measuring urine output. Assessing the color of the urine can provide some information about kidney function, but measuring output gives a more accurate assessment. Ensuring the catheter tubing is secure is essential to prevent dislodgement but is not the most critical assessment to make at this time.
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