HESI LPN
Fundamentals of Nursing HESI
1. Which of the following manifestations confirms the presence of pediculosis capitis in students?
- A. Scratching the head more than usual
- B. Flakes evident on a student's shoulders
- C. Oval pattern occipital hair loss
- D. Whitish oval specks sticking to the hair
Correct answer: D
Rationale: The correct answer is D. Whitish oval specks sticking to the hair shaft are nits, which are a definitive sign of pediculosis capitis (head lice). A: Scratching the head more than usual is a common symptom but not confirmatory of head lice infestation. B: Flakes evident on a student's shoulders may indicate dandruff or dry scalp, not necessarily head lice. C: Oval pattern occipital hair loss is not a typical manifestation of pediculosis capitis.
2. The nurse is working on an orthopedic rehabilitation unit that requires lifting and positioning of patients. Which personal injury will the nurse most likely try to prevent?
- A. Arm
- B. Hip
- C. Back
- D. Ankle
Correct answer: C
Rationale: The correct answer is C: Back. Back injuries are common among healthcare workers, especially nurses, due to improper lifting techniques and bending. Working on an orthopedic rehabilitation unit involves frequent lifting and positioning of patients, putting the nurse at risk of back injuries. Preventing back injuries is crucial for maintaining the nurse's health and ability to provide care effectively. Choices A, B, and D are incorrect because while lifting and positioning patients may involve these body parts, back injuries are most likely to occur due to the strain and stress placed on the back during such activities.
3. A client receives the influenza vaccine in a clinic. Within 15 minutes after the immunization, the client complains of itchy and watery eyes, increased anxiety, and difficulty breathing. What should be the first action in the sequence of care for this client?
- A. Maintain the airway
- B. Administer epinephrine 1:1000 as ordered
- C. Monitor for hypotension with shock
- D. Administer diphenhydramine as ordered
Correct answer: B
Rationale: In the scenario described, the client is experiencing symptoms of an anaphylactic reaction, a severe allergic response. The priority action in an anaphylactic reaction is to administer epinephrine. Epinephrine helps counteract the severe allergic response, improves breathing difficulties, and maintains airway and circulation. Administering epinephrine takes precedence to stabilize the client's condition. Options A, C, and D may be necessary in the management of anaphylaxis, but the immediate priority is to administer epinephrine to address the life-threatening symptoms.
4. A client with chronic back pain asks a nurse about receiving acupuncture for relief. Which of the following findings should the nurse identify as a contraindication to receiving this treatment?
- A. Obesity
- B. Hypertension
- C. Migraines
- D. Cellulitis
Correct answer: D
Rationale: The correct answer is D, Cellulitis. Cellulitis is a contraindication for acupuncture due to the risk of infection. Acupuncture involves inserting needles into the skin, and if a person has cellulitis, which is a bacterial skin infection, there is a higher risk of introducing the infection deeper into the body. Obesity (choice A), hypertension (choice B), and migraines (choice C) are not contraindications for receiving acupuncture. These conditions do not pose a direct risk of complications related to acupuncture treatment.
5. During an admission assessment, a healthcare professional finds a client's radial pulse rate to be 68/min and the simultaneous apical pulse to be 84/min. What is the client’s pulse deficit (per minute)?
- A. 16
- B. 12
- C. 6
- D. 14
Correct answer: A
Rationale: The pulse deficit is calculated by finding the difference between the apical and radial pulse rates. In this case, the difference is 84 - 68 = 16. This indicates that there is a pulse deficit of 16 beats per minute. Choices B, C, and D are incorrect as they do not accurately reflect the difference between the two pulse rates.
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