HESI LPN
Adult Health 1 Final Exam
1. Which client is at the highest risk for developing pressure ulcers?
- A. A 50-year-old client with a fractured femur
- B. A 30-year-old client with diabetes mellitus
- C. A 65-year-old client with limited mobility
- D. A 70-year-old client with a history of stroke
Correct answer: C
Rationale: Clients with limited mobility are at the highest risk for developing pressure ulcers due to prolonged pressure on specific areas of the body. This constant pressure can lead to tissue damage and ultimately result in pressure ulcers. While age and medical conditions such as diabetes and a history of stroke can contribute to the risk of pressure ulcers, limited mobility is the most significant factor as it directly affects the ability to shift positions and relieve pressure on vulnerable areas of the body. Therefore, the 65-year-old client with limited mobility is at the highest risk compared to the other clients. The 50-year-old client with a fractured femur may have limited mobility due to the injury, but it is temporary and may not be as prolonged as chronic limited mobility. The 30-year-old client with diabetes mellitus and the 70-year-old client with a history of stroke are at risk for developing pressure ulcers, but their conditions do not directly impact their ability to shift positions and alleviate pressure like limited mobility does.
2. After a 26-year-old gravida 4, para 0 experienced a spontaneous abortion at 9 weeks gestation, how should the nurse intervene after observing the client crying softly one hour post dilation and curettage (D&C)?
- A. Offer to call the social worker to discuss the possibility of adoption
- B. Reassure the client that the infertility specialist can help
- C. Express sorrow for the client's grief and offer to sit with her
- D. Chart the vital signs and amount of vaginal bleeding
Correct answer: C
Rationale: After a traumatic experience like a spontaneous abortion, it is crucial for the nurse to provide emotional support. Expressing sorrow for the client's grief and offering to sit with her demonstrates empathy and allows the client to process her emotions. Options A and B focus on future possibilities and medical interventions, which may not be immediately appropriate. Option D, while important for monitoring the client's physical status, does not address the client's emotional needs at that moment.
3. When taking blood pressure at the brachial artery, the nurse should place the client's arm in which position?
- A. Slightly above the level of the heart
- B. At the level of the heart
- C. At a level of comfort for the client
- D. Below the level of the heart
Correct answer: B
Rationale: When taking blood pressure at the brachial artery, it is crucial to place the client's arm at the level of the heart to ensure accurate measurement. Placing the arm above or below the heart level can lead to incorrect readings. Option A, placing the arm slightly above the heart level, would result in falsely lower blood pressure readings as gravity would assist in a lower value. Option C, placing the arm at a level of comfort for the client, may not align with the standardized technique required for accurate blood pressure assessment. Option D, placing the arm below the level of the heart, would likely yield falsely higher blood pressure readings due to increased hydrostatic pressure pushing the blood against gravity.
4. A client with a history of peptic ulcer disease (PUD) is prescribed omeprazole (Prilosec). What is the primary action of this medication?
- A. Neutralizes stomach acid
- B. Reduces gastric acid production
- C. Forms a protective barrier over ulcers
- D. Increases gastric mucus production
Correct answer: B
Rationale: The correct answer is B: Reduces gastric acid production. Omeprazole is a proton pump inhibitor that works by reducing gastric acid production, thereby helping to heal ulcers. While neutralizing stomach acid is associated with antacids, forming a protective barrier over ulcers is more characteristic of medications like sucralfate. The action described in choice D, increasing gastric mucus production, is not the primary mechanism of action of omeprazole in treating peptic ulcer disease.
5. The nurse is caring for a client with a diagnosis of major depressive disorder who has been prescribed fluoxetine (Prozac). What is the most important teaching point?
- A. Take the medication with or without food.
- B. Report any increase in suicidal thoughts.
- C. Avoid foods high in tyramine.
- D. Expect improvement within 24 hours.
Correct answer: B
Rationale: The correct teaching point is to instruct the client to report any increase in suicidal thoughts. This is crucial because SSRIs like fluoxetine can initially increase suicidal ideation, especially at the beginning of treatment. Choice A is corrected to emphasize that fluoxetine can be taken with or without food. Choice C is unrelated as it pertains more to MAOIs than SSRIs like fluoxetine. Choice D is inaccurate as antidepressants like fluoxetine may take weeks to show significant improvement in symptoms, not within 24 hours.
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