HESI LPN
Adult Health Exam 1 Chamberlain
1. A new mother is at the clinic with her 4-week-old for a well-baby check-up. The nurse should tell the mother to anticipate that the infant will demonstrate which milestone by 2 months of age?
- A. Turns from side to back and returns
- B. Consistently returns smiles to mother
- C. Finds hands and plays with fingers
- D. Holds head up and supports weight with arms
Correct answer: B
Rationale: The correct answer is B because social smiling is a developmental milestone typically expected around 2 months of age. At this stage, infants start to engage more with their caregivers and show positive emotional responses. The other choices are incorrect. Choice A describes a motor skill that usually emerges later. Choice C involves more coordination and exploration, which is not typically seen by 2 months. Choice D relates to head control and arm strength, which also develop progressively but may not be fully achieved by 2 months.
2. A client with a chronic illness expresses frustration over their condition. What is the nurse's best response to support the client?
- A. Encourage joining a support group for emotional support
- B. Discuss the possibility of a cure in the future
- C. Suggest focusing on positive aspects of their life
- D. Validate their feelings and listen to their concerns
Correct answer: D
Rationale: The best response for the nurse to support a client expressing frustration over their chronic illness is to validate their feelings and listen to their concerns (Option D). This approach helps acknowledge the client's emotions, demonstrates empathy, and establishes a therapeutic relationship. By validating the client's feelings and actively listening to their concerns, the nurse offers a supportive environment for the client to express their frustrations. Choices A, B, and C are not the best responses in this situation. While joining a support group, discussing a cure, or focusing on positive aspects can be beneficial interventions, the immediate priority is to validate the client's feelings and provide a space for them to express their frustrations.
3. The client with hypertension is being taught about lifestyle modifications. What topic is most important?
- A. Stress management
- B. Salt intake reduction
- C. Regular physical activity
- D. Weight loss
Correct answer: B
Rationale: Reducing salt intake is crucial for managing hypertension. Excessive salt consumption can lead to fluid retention, increasing blood pressure. While stress management, regular physical activity, and weight loss are beneficial for overall health, reducing salt intake is the most important lifestyle modification for controlling hypertension. Stress management may help reduce overall stress levels but does not directly impact blood pressure as salt intake does. Regular physical activity and weight loss can also benefit blood pressure control, but the immediate impact of reducing salt intake is more significant.
4. During the shift change report at an acute care hospital, the charge nurse assigns the Licensed Practical Nurse (LPN) to care for a client. Which task is within the LPN's scope?
- A. Administering IV medication
- B. Conducting initial client assessments
- C. Providing wound care for a stage III pressure ulcer
- D. Teaching a diabetic client about insulin administration
Correct answer: C
Rationale: The correct answer is C. LPNs are trained to provide basic nursing care such as wound care. Providing wound care for a stage III pressure ulcer falls within the LPN's scope of practice. Administering IV medication (choice A) requires a higher level of skill and is usually the responsibility of registered nurses. Conducting initial client assessments (choice B) demands more advanced training and is typically performed by registered nurses. Teaching a diabetic client about insulin administration (choice D) involves patient education and is usually within the scope of registered nurses or other healthcare professionals with specific training in diabetic care.
5. The nurse is caring for a 75-year-old male client who is beginning to form a decubitus ulcer at the coccyx. Which intervention will be most helpful in preventing further development of the decubitus ulcer?
- A. Encourage the client to eat foods high in protein
- B. Assess the client for daily range of motion exercises
- C. Teach the family how to perform sterile wound care
- D. Ensure the IV fluids are administered as prescribed
Correct answer: A
Rationale: Encouraging the client to eat foods high in protein is crucial in preventing further development of decubitus ulcers as high protein foods support tissue repair and skin integrity. Adequate protein intake is essential for wound healing. Assessing the client for daily range of motion exercises is important for preventing complications related to immobility, but it may not directly address the prevention of decubitus ulcers. Teaching the family how to perform sterile wound care is significant for wound management but may not be the most effective intervention to prevent further development of decubitus ulcers. Ensuring IV fluids are administered as prescribed is essential for maintaining hydration status but is not the most relevant intervention for preventing decubitus ulcers.
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