HESI LPN
Fundamentals HESI
1. A male client presents to the clinic stating that he has a high-stress job and is having difficulty falling asleep at night. The client reports having a constant headache and is seeking medication to help with sleep. Which intervention should the nurse implement?
- A. Determine the client's sleep and activity pattern
- B. Obtain a prescription for the client to take when stressed
- C. Refer the client for a sleep study and neurological follow-up
- D. Teach coping strategies to use when feeling stressed
Correct answer: A
Rationale: The correct intervention for the nurse to implement in this scenario is to determine the client's sleep and activity pattern. By assessing the client's patterns, the nurse can identify factors contributing to the sleep issues and tailor appropriate interventions. Choice B is incorrect because prescribing medication without a comprehensive assessment is not the initial step. Choice C is unnecessary at this stage as the client's symptoms are likely related to stress rather than a neurological disorder. Choice D, while important, should come after understanding the client's sleep patterns to provide holistic care. Therefore, option A is the best choice to address the client's sleep difficulties and headaches effectively.
2. When admitting a client, what information should the nurse record in the client’s record first?
- A. Assessment of the client
- B. Client’s medical history
- C. Plan of care
- D. Vital signs
Correct answer: A
Rationale: When admitting a client, the nurse's first step should be to assess the client. Assessment is crucial as it helps establish a baseline of the client's condition, identify any immediate concerns, and guide the development of an individualized plan of care. Recording the client's medical history, plan of care, or vital signs may follow the initial assessment but are secondary to the primary assessment process.
3. A client with a terminal illness asks the nurse about what would happen if she arrived at the emergency department and had difficulty breathing, despite declining resuscitation in her living will. Which of the following responses should the nurse provide?
- A. We will determine who the durable power of attorney for health care form has designated.
- B. We will apply oxygen through a tube in your nose.
- C. We will ask if you have changed your mind.
- D. We will insert a breathing tube while we evaluate your condition.
Correct answer: B
Rationale: The correct response is to provide oxygen through a tube in the client's nose. Oxygen therapy can offer comfort and support breathing without being considered resuscitative. Therefore, this intervention aligns with the client's wish to decline resuscitation. Option A is not directly related to addressing the client's immediate breathing difficulty. Option C does not acknowledge the client's living will decision. Option D involves a more invasive procedure that may go against the client's wishes to decline resuscitation.
4. A nurse in a health clinic is caring for a 20-year-old client who tells the nurse that their last physical exam was in high school. Which of the following health screenings should the nurse expect the provider to perform for this client?
- A. Testicular examination
- B. Blood glucose
- C. Fecal occult blood
- D. Prostate-specific antigen
Correct answer: A
Rationale: A testicular examination is appropriate for a 20-year-old male to screen for testicular cancer, which is more common in younger age groups. Testicular cancer is most frequently diagnosed in individuals between the ages of 15 and 40. Blood glucose screening is typically recommended for older individuals or those at risk for diabetes. Fecal occult blood testing is used for colorectal cancer screening, usually starting at age 50. Prostate-specific antigen testing is commonly considered for prostate cancer screening in older males, typically around age 50. Therefore, the most appropriate screening for the 20-year-old client is the testicular examination.
5. A young mother of three children complains of increased anxiety during her annual physical exam. What information should the LPN/LVN obtain first?
- A. Sexual activity patterns.
- B. Nutritional history.
- C. Leisure activities.
- D. Financial stressors.
Correct answer: B
Rationale: The LPN/LVN should first obtain the nutritional history in this scenario. Nutrition plays a crucial role in mental health, and deficiencies or imbalances in diet can contribute to anxiety symptoms. Understanding the mother's nutritional intake can help identify any factors exacerbating her anxiety. Sexual activity patterns are not directly relevant to her anxiety symptoms unless specifically indicated. Leisure activities and financial stressors may be important but are secondary to addressing the potential impact of nutrition on anxiety.
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