the pn is caring for a client with schizophrenia who continues to repeat the last words heard which nursing problem should the pn document in the medi
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HESI LPN

HESI PN Exit Exam

1. The PN is caring for a client with schizophrenia who continues to repeat the last words heard. Which nursing problem should the PN document in the medical record?

Correct answer: D

Rationale: The correct answer is D: Disturbed thought processes. Echolalia, the repetition of heard words, is associated with disturbed thought processes, which are commonly seen in schizophrenia. Altered thought processes (Choice A) is a generic term and does not specifically address the behavior of repeating words. Impaired social interaction (Choice B) is not the primary concern when a client repeats the last words heard. Risk for self-directed violence (Choice C) is not directly related to the behavior of repeating words but focuses on the potential harm the client may cause to themselves.

2. The single mother of a child with a head injury is sitting at the child's bedside crying when the PN enters the room. The mother states, 'Why did this happen to my child? I just can't cope with this.' How should the PN respond?

Correct answer: C

Rationale: Expressing empathy and acknowledging the mother's feelings helps in providing emotional support during a difficult time. This response validates her emotions and offers a comforting presence. Choice A is not appropriate as it focuses on gathering information rather than addressing the mother's emotional distress. Choice B may come off as dismissive of the mother's feelings and oversimplifies the complexity of the situation. Choice D shifts the responsibility to someone else instead of offering immediate support and comfort.

3. A client post-mastectomy is concerned about the risk of lymphedema. What should the nurse include in the discharge instructions to minimize this risk?

Correct answer: B

Rationale: To minimize the risk of lymphedema after a mastectomy, it is essential to instruct the client to avoid venipunctures and blood pressure measurements on the affected arm. These procedures can lead to trauma or impede lymphatic flow, increasing the risk of lymphedema. Wearing compression garments helps manage lymphedema but is not preventive. Performing vigorous exercises can strain the affected arm and increase the risk of lymphedema. Keeping the affected arm elevated at all times is unnecessary and not an effective preventive measure against lymphedema.

4. What is the first action a healthcare professional should take when a patient’s nasogastric (NG) tube becomes clogged?

Correct answer: C

Rationale: When a patient's nasogastric (NG) tube becomes clogged, the first action to take is to attempt to aspirate the clog with a syringe. This is a standard and initial step to clear the blockage in the tube. Flushing the tube with water (Choice A) may not address the specific clog; repositioning the patient (Choice B) is not directly related to clearing the tube. Administering a medication to dissolve the clog (Choice D) should only be considered after simpler methods like aspiration have been attempted.

5. When administering parenteral iron, which action would be inconsistent with proper administration?

Correct answer: D

Rationale: The correct answer is D: Using the deltoid muscle for administration. Administering parenteral iron in the deltoid muscle is not recommended due to the risk of irritation and pain. The Z-track method (choice A) is preferred to prevent staining and irritation of the skin when administering irritating medications like iron. Using an air bubble (choice B) to avoid withdrawing medication into subcutaneous tissue is a common practice to ensure accurate administration. Not massaging the injection site (choice C) is also a standard practice to prevent potential irritation or bleeding at the injection site.

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