HESI LPN
Fundamentals of Nursing HESI
1. A nurse is caring for two clients who report following the same religion. Which of the following information should the nurse consider when planning care for these clients?
- A. Members of the same religion may have varying feelings about their religion.
- B. A shared religion background does not guarantee identical beliefs.
- C. The same religious beliefs can influence individuals differently.
- D. Discussing differences and commonalities in beliefs may not always be relevant.
Correct answer: C
Rationale: The correct answer is C. Religious beliefs can vary widely even among individuals of the same faith. It is essential for the nurse to recognize that the impact and interpretation of religious beliefs can differ from person to person. Choice A is incorrect as individuals within the same religion can have diverse feelings and interpretations. Choice B is incorrect because a shared religious background does not necessarily mean that individuals hold the same beliefs. Choice D is not the best course of action as discussing differences and commonalities in beliefs may not always be necessary or appropriate for providing care.
2. A nurse is caring for an adolescent client who has full-thickness burns on his leg. The client expresses concern about his future. Which of the following is a therapeutic response by the nurse?
- A. “You’re concerned about what will happen when you leave the hospital?”
- B. “If you work hard on your physical therapy, you won’t need to worry.”
- C. “You shouldn’t worry about the future so you can concentrate on getting well.”
- D. “Why are you concerned even though everyone is here to help you?”
Correct answer: A
Rationale: The correct response is A, “You’re concerned about what will happen when you leave the hospital?” This response acknowledges the client's concerns about the future, validating their feelings and encouraging open communication. It shows empathy and allows the client to express their worries. Choice B minimizes the client's concerns by suggesting that they won't need to worry if they work hard on physical therapy, which may invalidate their emotions. Choice C dismisses the client's worry, implying that they should ignore their concerns to focus on getting well. Choice D uses a confrontational approach by questioning the client's concerns, which may discourage open communication and make the client feel defensive.
3. A nurse in a provider's office is preparing to assess a young adult client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect?
- A. Concave thoracic spine posteriorly
- B. Exaggerated lumbar curvature
- C. Concave lumbar spine posteriorly
- D. Exaggerated thoracic curvature
Correct answer: B
Rationale: When assessing a young adult's musculoskeletal system, the nurse should expect an exaggerated lumbar curvature (lordosis). This is a normal finding in young adults due to the natural curvature of the spine. Concave thoracic spine posteriorly (choice A) and concave lumbar spine posteriorly (choice C) are not typical findings as the spine should have normal curvatures. Exaggerated thoracic curvature (choice D) is also not a typical finding in young adults.
4. When should discharge planning for a patient admitted to the neurological unit with a diagnosis of stroke begin?
- A. At the time of admission
- B. The day before the patient is to be discharged
- C. When outpatient therapy is no longer needed
- D. As soon as the patient's discharge destination is known
Correct answer: A
Rationale: Discharge planning for a patient admitted to the neurological unit with a stroke diagnosis should begin at the time of admission. Initiating discharge planning early allows for a comprehensive assessment of the patient's needs, enables better coordination of care, and ensures a smooth transition from the hospital to the next level of care. Option B is incorrect because waiting until the day before discharge does not provide enough time for adequate planning. Option C is incorrect because waiting until outpatient therapy is no longer needed delays the planning process. Option D is incorrect because waiting until the discharge destination is known may result in rushed planning and inadequate preparation for the patient's needs.
5. A healthcare professional is assessing a client’s extraocular eye movements. Which of the following should the professional do?
- A. Instruct the client to follow a finger through the six cardinal positions of gaze.
- B. Hold a finger 46 cm (18 in) away from the client’s eyes.
- C. Ask the client to cover their right eye during assessment of the left eye.
- D. Position the client 6.1 m (20 feet) away from the Snellen chart.
Correct answer: A
Rationale: Instructing the client to follow a finger through the six cardinal positions of gaze is the correct action when assessing extraocular eye movements. This technique assesses the movement of the eyes in all directions and helps to test cranial nerves 3, 4, and 6, which control eye movements. Choice B is incorrect as the distance mentioned is not relevant for assessing extraocular eye movements. Choice C is incorrect as both eyes need to be assessed independently. Choice D is incorrect as positioning the client 6.1 m (20 feet) away from the Snellen chart is related to visual acuity testing, not extraocular eye movements.
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