HESI LPN
HESI Fundamentals Exam
1. The nurse is caring for a client with hyperthyroidism. Which finding should the nurse expect to observe in this client?
- A. Weight loss
- B. Cold intolerance
- C. Bradycardia
- D. Dry skin
Correct answer: A
Rationale: Weight loss is a common finding in clients with hyperthyroidism due to increased metabolic activity. Hyperthyroidism leads to an overactive thyroid gland, which results in an increased metabolic rate and often leads to weight loss despite a normal or increased appetite. Cold intolerance (Choice B) is more commonly associated with hypothyroidism, where the body's processes slow down. Bradycardia (Choice C) is a slow heart rate, which is not typically seen in hyperthyroidism; rather, tachycardia or an increased heart rate is more common. Dry skin (Choice D) is also not a typical finding in hyperthyroidism, as the skin is more likely to be warm and moist due to increased metabolic activity.
2. A client scheduled for a hysterectomy has not yet signed the operative consent form. When the nurse approaches the client and asks that she review and sign the form, the client says she no longer wants to have the surgery. At this time, which action should the nurse take?
- A. Ask the client why she has changed her mind
- B. Proceed with the surgery
- C. Notify the surgeon immediately
- D. Document the client’s decision
Correct answer: A
Rationale: The correct action for the nurse to take in this situation is to ask the client why she has changed her mind. By understanding the client's reasons for refusal, the nurse can address any concerns, provide further information, and ensure that the client's decision is respected. Proceeding with the surgery without clarifying the client's decision or notifying the surgeon immediately would not be appropriate. Documenting the client's decision is important, but it should be done after understanding the rationale behind the decision.
3. During a neurologic examination, which assessment should a nurse perform to test a client's balance?
- A. Romberg test
- B. Heel-to-toe walk
- C. Snellen test
- D. Spinal accessory function
Correct answer: A
Rationale: The Romberg test is used to assess a client's balance by evaluating their ability to maintain a steady posture with eyes closed. The heel-to-toe walk is another assessment that tests balance by assessing gait and coordination. The Snellen test is used to assess visual acuity and is unrelated to balance. Testing spinal accessory function involves assessing the movement of the head and shoulders and is not directly related to balance assessment.
4. A client who is terminally ill has a family member who is coping effectively with the situation. Which of the following statements should the nurse identify as an indication of effective coping?
- A. "We still have hope that everything will be okay."
- B. "This is a difficult time, but we are helping each other through this."
- C. "After he comes home, we can plan out a family reunion."
- D. "We don't need to talk about funeral arrangements at this time."
Correct answer: B
Rationale: The correct answer is B because an effective coping strategy involves mutual support and communication within the family. This statement reflects effective coping skills as the family is shown to be helping each other through the difficult time. Choice A is incorrect as maintaining hope does not necessarily indicate effective coping. Choice C focuses on future events and may not address the current situation of coping with a terminally ill family member. Choice D avoids discussing important aspects of end-of-life planning, which may not reflect effective coping with the situation at hand.
5. A client with stage IV lung cancer is 3 days postoperative following a wedge resection. The client states, “I told myself that I would go through with the surgery and quit smoking, if I could just live long enough to attend my child’s wedding.” Based on the Kubler-Ross model, which stage of grief is the client experiencing?
- A. Anger
- B. Denial
- C. Bargaining
- D. Acceptance
Correct answer: C
Rationale: The client is in the bargaining stage of grief according to the Kubler-Ross model. In this stage, individuals negotiate for more time to achieve specific goals or fulfill desires. The client's statement about quitting smoking to attend their child's wedding reflects this bargaining behavior. Anger (choice A) is characterized by frustration and resentment, denial (choice B) involves avoidance of reality, and acceptance (choice D) signifies coming to terms with the situation, none of which align with the client's current mindset of bargaining.
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