HESI LPN
HESI CAT Exam 2024
1. A male client, admitted to the mental health unit for a somatoform disorder, becomes angry because he cannot have his pain medication. He demands that the nurse call the healthcare provider and threatens to leave the hospital. What action should the nurse take?
- A. Place the client in seclusion per unit guidelines
- B. Administer a PRN prescription for lorazepam (Ativan)
- C. Call security to help ensure staff and client safety
- D. Ask what other methods he uses to deal with pain
Correct answer: C
Rationale: In this scenario, the nurse should prioritize ensuring safety. When a client becomes aggressive and threatens to leave, calling security is crucial to help maintain a safe environment for both staff and the client. Placing the client in seclusion (choice A) is not the appropriate initial action as it may escalate the situation further. Administering lorazepam (choice B) should not be the first response to behavioral issues. Asking about other pain management methods (choice D) is not the immediate priority when safety is at risk.
2. A 70-year-old client is admitted to the hospital after 24 hours of acute diarrhea. To determine fluid status, which initial data is most important for the nurse to obtain?
- A. Usual and current weight
- B. Color and amount of urine
- C. Number and frequency of stools
- D. Intake and output 24 hours prior to admission
Correct answer: A
Rationale: The correct answer is A: Usual and current weight. Weight changes are the most direct indicator of fluid status in a patient with acute diarrhea. Monitoring weight loss or gain can provide crucial information about fluid balance. Option B, color and amount of urine, though important for assessing renal function, is not as direct an indicator of fluid status as weight. Option C, number and frequency of stools, is relevant for assessing the severity of diarrhea but does not provide direct information on fluid status. Option D, intake and output 24 hours prior to admission, does not reflect the current fluid status and may not be accurate in a rapidly changing condition like acute diarrhea.
3. After undergoing an uncomplicated gastric bypass surgery, a client is experiencing difficulty managing their diet. What dietary instruction is most important for the nurse to explain to the client?
- A. Chew food slowly and thoroughly before attempting to swallow
- B. Plan volume-controlled evenly spaced meals throughout the day
- C. Sip fluid slowly with each meal and between meals
- D. Eliminate or reduce intake of fatty and gas-forming foods
Correct answer: A
Rationale: The correct answer is A. Thoroughly chewing food is crucial for clients who have undergone gastric bypass surgery to aid in digestion and prevent complications. Proper chewing helps break down food into smaller particles, making it easier for the digestive system to process. This instruction is essential to prevent issues such as food blockages or inadequate nutrient absorption. Choices B and C are also important for post-gastric bypass clients to maintain proper nutrition and hydration, but they are not as critical as ensuring thorough chewing. Choice D addresses dietary concerns but is not as immediately crucial as ensuring the client chews food properly to support digestion and prevent complications.
4. When designing a program to provide primary preventative health care to a community-based healthcare system, which service should the nurse consider for inclusion in the program? Select all that apply.
- A. Breast screening for older women
- B. Rehabilitation services for stroke victims
- C. Blood pressure assessments
- D. Antepartum nutritional counseling
Correct answer: A
Rationale: The correct answer is A: Breast screening for older women. In the context of primary preventative health care, breast screening for older women is crucial for early detection of breast cancer. Choice B, rehabilitation services for stroke victims, focuses on rehabilitative care rather than primary preventative care. Choice C, blood pressure assessments, is important for monitoring health status but not exclusive to primary prevention. Choice D, antepartum nutritional counseling, is more related to prenatal care than primary preventative health care. Therefore, choices B, C, and D do not directly align with the primary preventative health care objective of the grant.
5. A male client with schizophrenia tells the nurse that the hospital has installed cameras that watch him and listening devices that record what everyone says. Which nursing problem should the nurse document for this client?
- A. Noncompliance with medication related to thought broadcasting
- B. Situational self-esteem disturbance secondary to schizophrenia
- C. Disturbed sensory perception related to auditory hallucinations
- D. Impaired environmental interpretation related to paranoid delusions
Correct answer: D
Rationale: The correct answer is D: Impaired environmental interpretation related to paranoid delusions. The client's belief about cameras watching and recording him is a manifestation of paranoid delusions, indicating a misinterpretation of the environment. Choice A is incorrect because thought broadcasting is not directly related to the client's belief about surveillance equipment. Choice B is incorrect as self-esteem disturbance is not the primary issue presented. Choice C is also incorrect as the client is not experiencing auditory hallucinations but rather paranoid delusions about surveillance.
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