adult health exam 1 Adult Health Exam 1 - Nursing Elites
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Nursing Elites

HESI LPN

Adult Health Exam 1

1. An adult female client is admitted to the psychiatric unit with a diagnosis of major depression. After 2 weeks of antidepressant medication therapy, the nurse notices the client has more energy, is giving her belongings away to her visitors, and is in an overall better mood. Which intervention is best for the nurse to implement?

Correct answer: B

Rationale: In this scenario, the nurse should ask the client if she has had any recent thoughts of harming herself. Sudden mood improvements and behavioral changes, like giving away belongings, can be concerning signs of possible suicidal ideation. Assessing for suicidal thoughts is crucial to ensure the client's safety. Choice A is incorrect as it does not address the potential risk of harm or assess for suicidal ideation. Choice C is incorrect because simply reassuring the client about the effectiveness of antidepressants does not address the immediate concern of suicidal ideation. Choice D is incorrect as it focuses on praising progress without addressing the potential risk of harm the client may pose to herself.

2. A client with a history of atrial fibrillation is prescribed warfarin. Which lab value should the nurse monitor to assess the effectiveness of this medication?

Correct answer: D

Rationale: The correct answer is D, INR (International Normalized Ratio). The INR is used to monitor the effectiveness of warfarin therapy. Warfarin is an anticoagulant medication commonly prescribed for conditions like atrial fibrillation. Monitoring the INR helps healthcare providers ensure that the blood is clotting within a therapeutic range. Hemoglobin (Choice A), white blood cell count (Choice B), and platelet count (Choice C) are not directly related to monitoring the effectiveness of warfarin therapy in this context.

3. Which nursing activity is within the scope of practice for the practical nurse?

Correct answer: C

Rationale: The correct answer is C: 'Observe a client rotate the subcutaneous site for an insulin pump.' This activity is within the scope of practice for a practical nurse as it involves observing and ensuring proper technique for using an insulin pump, which aligns with their training and responsibilities. Choices A, B, and D are beyond the typical scope of practice for a practical nurse. Completing an admission assessment for a newborn nursery is usually performed by a registered nurse. Discontinuing a dislodged central venous catheter and monitoring a narcotic epidural require advanced skills and knowledge, usually carried out by registered nurses or advanced practice nurses.

4. The nurse plans to administer the rubella vaccine to a postpartum client whose titer is < 1:8 and who is breastfeeding. What information should the nurse provide this client?

Correct answer: D

Rationale: Educating about the waiting period helps prevent possible rubella infection in a subsequent early pregnancy.

5. A client with hypothyroidism is being treated with levothyroxine (Synthroid). What is the most important information for the nurse to provide to the client?

Correct answer: B

Rationale: The most important information for the nurse to provide to a client with hypothyroidism being treated with levothyroxine is to monitor for signs of hyperthyroidism. Too much levothyroxine can lead to symptoms of hyperthyroidism, indicating an overdose. Choice A is incorrect as levothyroxine is usually taken on an empty stomach to ensure optimal absorption. Choice C is inaccurate as it may take weeks to months to see the full effects of levothyroxine therapy due to the need for dosage adjustments. Choice D is unrelated to levothyroxine therapy and is not a crucial concern for this specific medication.

Similar Questions

A client with hypothyroidism is being treated with levothyroxine (Synthroid). What is the most important information for the nurse to provide to the client?
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A client with heart failure is prescribed a low-sodium diet. The nurse notices the client's meal tray contains high-sodium foods. What action should the nurse take?
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