HESI LPN
Adult Health Exam 1 Chamberlain
1. A new mother is at the clinic with her 4-week-old for a well-baby check-up. The nurse should tell the mother to anticipate that the infant will demonstrate which milestone by 2 months of age?
- A. Turns from side to back and returns
- B. Consistently returns smiles to mother
- C. Finds hands and plays with fingers
- D. Holds head up and supports weight with arms
Correct answer: B
Rationale: The correct answer is B because social smiling is a developmental milestone typically expected around 2 months of age. At this stage, infants start to engage more with their caregivers and show positive emotional responses. The other choices are incorrect. Choice A describes a motor skill that usually emerges later. Choice C involves more coordination and exploration, which is not typically seen by 2 months. Choice D relates to head control and arm strength, which also develop progressively but may not be fully achieved by 2 months.
2. During a severe asthma exacerbation in a client, what is the nurse's priority?
- A. Administer a rescue inhaler immediately
- B. Prepare for intubation
- C. Encourage deep breathing exercises
- D. Monitor oxygen saturation levels
Correct answer: A
Rationale: During a severe asthma exacerbation, the nurse's priority is to administer a rescue inhaler immediately. This action helps open the airways and improve breathing, which is crucial in managing the exacerbation. Choice B, preparing for intubation, would be considered if the client's condition deteriorates and they are unable to maintain adequate oxygenation even after using the rescue inhaler. Encouraging deep breathing exercises (Choice C) may not be appropriate during a severe exacerbation as the client may struggle to breathe. While monitoring oxygen saturation levels (Choice D) is important, the immediate administration of a rescue inhaler takes precedence to address the acute breathing difficulty.
3. Which of the following are key parameters that produce blood pressure? (Select ONE that does not apply)
- A. Heart rate
- B. Stroke volume
- C. Peripheral resistance
- D. Neuroendocrine hormones
Correct answer: D
Rationale: Heart rate, stroke volume, and peripheral resistance are indeed key parameters that directly influence blood pressure. Heart rate refers to the number of times the heart beats per minute, affecting how much blood is pumped. Stroke volume is the amount of blood pumped by the heart in one contraction. Peripheral resistance is the resistance of the arteries to blood flow, impacting the pressure needed to push blood through. Neuroendocrine hormones, while they can indirectly influence blood pressure regulation by affecting factors like blood volume and vascular tone, are not direct final parameters that produce blood pressure.
4. A nurse is developing a care plan for a client with chronic pain. What interventions should be included to help manage pain?
- A. Administer pain medication around the clock
- B. Teach relaxation techniques
- C. Encourage physical activity
- D. All of the above
Correct answer: D
Rationale: In managing chronic pain, it is essential to employ a multi-faceted approach. Administering pain medication around the clock helps maintain consistent pain relief. Teaching relaxation techniques such as deep breathing or guided imagery can help reduce muscle tension and promote relaxation, which can alleviate pain. Encouraging physical activity, tailored to the client's abilities, can help improve overall physical functioning and reduce pain perception. Therefore, combining all these interventions (pain medication, relaxation techniques, and physical activity) provides a comprehensive approach to pain management, addressing different aspects of the client's experience with chronic pain. This holistic approach is more effective than using a single intervention alone, making 'All of the above' the correct choice.
5. Which client assessment falls within the scope of practice for the practical nurse?
- A. An agitated client with bilateral wrist restraints
- B. New admission of a client with deep vein thrombosis
- C. Return of a post-anesthesia client following a colon resection
- D. Transfer of a client with sepsis from a long-term care facility
Correct answer: B
Rationale: The correct answer is B because assessing a new deep vein thrombosis (DVT) patient is within the scope of practical nursing. It involves monitoring and supporting the circulatory system health, which is a common responsibility for practical nurses. Choices A, C, and D involve scenarios that are typically beyond the initial assessment and care provided by practical nurses. An agitated client with bilateral wrist restraints may require immediate intervention by higher-level healthcare providers due to safety concerns and potential underlying issues. The return of a post-anesthesia client following a colon resection and the transfer of a client with sepsis involve more specialized care that goes beyond the typical responsibilities of a practical nurse, often requiring interventions from registered nurses or physicians.
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