a nurse is caring for a client who states i have to check with my partner and see if they think i am ready to go home the nurse replies how do you fee
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Nursing Elites

HESI LPN

HESI Fundamentals 2023 Test Bank

1. A client tells the nurse, “I have to check with my partner and see if they think I am ready to go home.” The nurse responds, “How do you feel about going home today?” Which clarifying technique is the nurse using to enhance communication with the client?

Correct answer: B

Rationale: Reflecting is the correct answer as it involves echoing back the client’s feelings and concerns, helping them explore their thoughts. In this scenario, the nurse mirrors the client's statement to encourage the client to delve deeper into their emotions. Pacing involves matching the rate and flow of communication, paraphrasing is restating in different words, and restating is repeating what the client said without adding new information. Therefore, choices A, C, and D are not the appropriate clarifying technique demonstrated in the situation described.

2. The client has expressive aphasia and needs assistance to communicate. Which method should the LPN use to best support the client's ability to express basic needs?

Correct answer: A

Rationale: The correct answer is to use a picture board with common needs. Clients with expressive aphasia have difficulty speaking but can often understand and use visual aids effectively. Using a picture board helps the client communicate basic needs more easily. Encouraging the client to speak slowly (choice B) may not be effective as the issue lies with expressive language, not speed. Writing down what the client says (choice C) may not always be possible or helpful for immediate communication as it does not address the communication barrier directly. Using hand gestures (choice D) may not be as clear or universally understood as a picture board, which can cause confusion and misinterpretation.

3. The nurse is preparing to administer insulin to a client with type 1 diabetes. Which assessment finding would require the nurse to hold the insulin and contact the healthcare provider?

Correct answer: A

Rationale: A blood glucose of 100 mg/dL is relatively low for administering insulin, especially if the client has not eaten adequately; further assessment and contacting the provider are necessary. Hypoglycemia can be a serious concern when administering insulin, and a blood glucose level of 100 mg/dL indicates a risk of hypoglycemia. Holding the insulin and contacting the healthcare provider is crucial to prevent hypoglycemia-related complications. Choices B, C, and D are not immediate concerns for holding insulin as they do not directly indicate a risk of hypoglycemic events.

4. The patient is being taught about flossing and oral hygiene. What instruction will the nurse include in the teaching session?

Correct answer: B

Rationale: The correct answer is B. Flossing is essential for removing plaque and tartar between teeth, contributing to better oral hygiene. Choice A is not entirely accurate as waxed floss may not solely prevent bleeding. Flossing three times a day, as mentioned in choice C, can be excessive and unnecessary, while choice D is incorrect as applying toothpaste before flossing is not harmful but might not provide additional benefits.

5. A 54-year-old male client and his wife were informed this morning that he has terminal cancer. Which nursing intervention is likely to be most appropriate?

Correct answer: A

Rationale: In this situation, it is crucial to involve the wife in the care of the client to provide support and empower her. Asking the wife how she would like to participate allows her to be actively involved in decision-making and caregiving. Providing information about hospice (choice B) might be premature as the couple may still be digesting the diagnosis. Encouraging the wife to visit during the treatment process (choice C) may not address her immediate need for involvement and support. Referring her to a support group for family members (choice D) is helpful but involving her directly in the client's care is a more immediate and personalized approach.

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