HESI LPN
Fundamentals HESI
1. Which statement made by a client indicates to the nurse that they may have a thought disorder?
- A. 'I'm so angry about this. Wait until my partner hears about this.'
- B. 'I'm a little confused. What time is it?'
- C. 'I can't find my missing shoes. Have you seen them?'
- D. 'I'm fine. It's my daughter who has the problem.'
Correct answer: C
Rationale: The statement 'I can't find my missing shoes. Have you seen them?' displays disorganized thinking or speech, which is characteristic of a thought disorder. The mention of 'missing shoes' in a context that does not make logical sense suggests a disturbance in thought processes. Choices A, B, and D do not demonstrate disorganized thinking typical of thought disorders. Option A reflects emotional expression, option B indicates mild confusion, and option D shows a redirection of focus to someone else's problem.
2. A client who has just had a mastectomy has a closed wound suction device (hemovac) in place. Which nursing action will ensure proper operation of the device?
- A. Collapsing the device whenever it is 1/2 to 2/3 full of air.
- B. Emptying the device every 4 hours.
- C. Replacing the device every 24 hours.
- D. Keeping the device above the level of the surgical site.
Correct answer: A
Rationale: Collapsing the device when it is 1/2 to 2/3 full of air is the correct nursing action to ensure proper operation of a closed wound suction device (hemovac). This action maintains negative pressure, which is essential for proper suction and drainage of the wound. Emptying the device every 4 hours (Choice B) is not necessary as the focus should be on collapsing it appropriately. Replacing the device every 24 hours (Choice C) is not a standard practice unless indicated by the healthcare provider. Keeping the device above the level of the surgical site (Choice D) is not necessary for the device's proper operation; collapsing it to maintain negative pressure is the key action.
3. During a family assessment, a nurse is interviewing a family composed of a husband, a wife, and three children. One child is biological from this marriage, and the other two are from the wife’s previous marriage. How should the nurse identify this family form?
- A. Extended
- B. Blended
- C. Nuclear
- D. Alternative
Correct answer: B
Rationale: The correct answer is 'Blended.' This family is considered a blended family because it consists of children from previous marriages, along with the biological child of the current marriage. Choice A ('Extended') refers to a family that includes relatives beyond the nuclear family, such as grandparents or aunts/uncles. Choice C ('Nuclear') typically consists of a husband, wife, and their biological children only. Choice D ('Alternative') does not accurately describe the family structure presented in the scenario.
4. While administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take?
- A. Have the client hold their breath briefly and bear down.
- B. Clamp the enema tubing.
- C. Remind the client that cramping is common at this time.
- D. Raise the level of the enema fluid container.
Correct answer: C
Rationale: When a client reports abdominal cramping during a cleansing enema, it is important for the nurse to reassure the client that cramping is a common side effect. This reassurance helps the client understand that the cramping is normal and may subside once the enema is completed. Instructing the client to hold their breath and bear down (Choice A) is not appropriate and may cause discomfort. Clamping the enema tubing (Choice B) is unnecessary and could lead to complications. Raising the level of the enema fluid container (Choice D) does not address the client's discomfort due to cramping. Therefore, the most suitable action is to provide reassurance to the client about the common occurrence of cramping during the enema.
5. A community health nurse is caring for a group of families. The nurse should identify which of the following families is experiencing a maturational loss?
- A. A family whose only child recently died due to cancer.
- B. A family whose head of household lost her job.
- C. A family whose house was destroyed in a fire.
- D. A family whose oldest child is moving away for college.
Correct answer: D
Rationale: The correct answer is D because maturational loss is related to developmental changes, such as children leaving for college. This type of loss is tied to the normal life transitions of individuals and can lead to feelings of grief and adjustment. Choices A, B, and C represent different types of losses. Choice A involves a traumatic loss of a child due to illness, choice B involves a financial loss impacting the head of household's job, and choice C involves a material loss due to a fire incident. While these losses are significant, they do not specifically relate to maturational loss, which is associated with expected life stage transitions.
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