HESI LPN
Medical Surgical Assignment Exam HESI
1. A client with Parkinson's disease is experiencing difficulty swallowing. Which intervention should the nurse implement to prevent aspiration?
- A. Encourage the client to eat quickly.
- B. Provide a straw for liquids.
- C. Place the client in an upright position during meals.
- D. Offer thin liquids.
Correct answer: C
Rationale: Placing the client in an upright position during meals is the correct intervention to prevent aspiration in a client with Parkinson's disease. This position helps facilitate swallowing and reduces the risk of aspiration. Choice A is incorrect because encouraging the client to eat quickly can increase the risk of choking and aspiration. Choice B is not the best option as straws may not prevent aspiration effectively. Choice D is incorrect as thin liquids can actually increase the risk of aspiration in individuals with swallowing difficulties.
2. When assessing an adolescent with depression, what is the most important question for the nurse to ask?
- A. What is causing your feelings of depression?
- B. Have you ever thought about suicide?
- C. What actions can we take to improve your mood?
- D. Would you like your friends to come over?
Correct answer: B
Rationale: The correct answer is B: 'Have you ever thought about suicide?' When assessing an adolescent with depression, it is crucial to ask direct questions about suicidal thoughts. This helps determine the severity of the situation, especially if the person has considered or planned to harm themselves. Choice A is not as direct and specific to suicidal ideation. Choice C focuses on improving mood rather than assessing the risk of harm. Choice D is unrelated to assessing suicidal ideation and the severity of the depression.
3. Which individual has the highest risk for developing skin cancer?
- A. A 16-year-old dark-skinned female who tans in tanning beds once a week.
- B. A 65-year-old fair-skinned male who is a construction worker
- C. A 25-year-old dark-skinned male whose mother had skin cancer.
- D. A 70-year-old fair-skinned female who works as a secretary.
Correct answer: B
Rationale: The correct answer is B, a 65-year-old fair-skinned male who is a construction worker. Fair-skinned individuals are at higher risk of developing skin cancer due to prolonged sun exposure. Construction workers are often exposed to the sun for long periods, further increasing the risk. Choices A, C, and D are less likely to develop skin cancer compared to choice B due to factors such as age, frequency of tanning bed use, and occupation.
4. Fluids are restricted to 1500 ml/day for a male client with AKI. He is frustrated and complaining of constant thirst, and the nurse discovers that the family is providing the client with additional fluids. What intervention should the nurse implement?
- A. Remove all sources of liquids from the client's room
- B. Allow family to give the client a measured amount of ice chips
- C. Restrict family visiting until the client's condition is stable
- D. Provide the client with oral swabs to moisten his mouth
Correct answer: D
Rationale: In this scenario, the nurse should provide the client with oral swabs to moisten his mouth. This intervention helps alleviate the client's thirst without increasing fluid intake, which is essential in managing AKI. Removing all sources of liquids from the client's room (Choice A) may not address the underlying issue of thirst and could lead to increased frustration. Allowing the family to give the client ice chips (Choice B) would add to the client's fluid intake, contradicting the restriction. Restricting family visiting (Choice C) is not necessary and does not directly address the client's thirst.
5. After hospitalization for SIADH, a client develops pontine myelinolysis. Which intervention should the nurse implement first?
- A. Reorient the client to the room
- B. Place an eye patch on one eye
- C. Evaluate the client's ability to swallow
- D. Perform range of motion exercises
Correct answer: C
Rationale: Evaluating the client's ability to swallow is the priority intervention in this scenario. Pontine myelinolysis can affect neurological functions, including swallowing ability, putting the client at risk for aspiration. Assessing the client's ability to swallow will help prevent complications such as aspiration pneumonia. Reorienting the client to the room, placing an eye patch, or performing range of motion exercises are not as critical as ensuring the client can safely swallow.
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