HESI LPN
HESI Fundamentals Study Guide
1. A client with Guillain-Barre syndrome is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?
- A. Comatose, breathing unlabored
- B. Glasgow Coma Scale 8, respirations regular
- C. Appears to be sleeping, vital signs stable
- D. Glasgow Coma Scale 13, no ventilator required
Correct answer: B
Rationale: A client with Guillain-Barre syndrome in a non-responsive state with stable vital signs and independent breathing would most accurately be described by a Glasgow Coma Scale of 8 with regular respirations. Choice A is incorrect as 'comatose' implies a deeper level of unconsciousness than described in the scenario. Choice C is incorrect as 'appears to be sleeping' is not an accurate description of a non-responsive state. Choice D is incorrect as a Glasgow Coma Scale of 13 indicates a higher level of consciousness than stated in the scenario.
2. A client has been admitted to the hospital with severe diarrhea. The nurse should monitor the client for which complication?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Hyperkalemia
- D. Hypercalcemia
Correct answer: A
Rationale: Severe diarrhea can lead to metabolic acidosis due to the loss of bicarbonate. When there is excessive loss of bicarbonate through diarrhea, the pH of the blood decreases, leading to metabolic acidosis. Metabolic alkalosis (Choice B) is not typically associated with severe diarrhea as it involves elevated pH and bicarbonate levels. Hyperkalemia (Choice C) is less likely with severe diarrhea as potassium is often lost along with fluids. Hypercalcemia (Choice D) is not a common complication of severe diarrhea; instead, hypocalcemia may occur due to malabsorption of calcium.
3. When admitting a 5-month-old who has vomited 9 times in the past 6 hours, what should the healthcare provider observe for signs of which overall imbalance?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Increased serum hemoglobin levels
- D. Decreased serum potassium levels
Correct answer: B
Rationale: When a 5-month-old infant vomits multiple times, there is a risk of developing metabolic alkalosis due to the loss of stomach acid. Metabolic alkalosis is characterized by elevated pH and bicarbonate levels. It is caused by the loss of hydrogen ions from the body, often through vomiting. Metabolic acidosis (choice A) is unlikely in this scenario because it is more commonly associated with conditions like renal failure or diabetic ketoacidosis. Choice C, increased serum hemoglobin levels, is not typically a direct consequence of vomiting. Choice D, decreased serum potassium levels, may occur with vomiting but is not the primary concern when a patient is vomiting excessively.
4. When a nurse assigned to a manipulative client for 5 days becomes aware of feelings of reluctance to interact with the client, what should be the next action by the nurse?
- A. Discuss the feeling of reluctance with an objective peer or supervisor
- B. Limit contact with the client to avoid reinforcement of the manipulative behavior
- C. Confront the client about the negative effects of behaviors on other clients and staff
- D. Develop a behavior modification plan that will promote more functional behavior
Correct answer: A
Rationale: The correct action for the nurse in this situation is to discuss the feeling of reluctance with an objective peer or supervisor. By doing so, the nurse can address their emotions professionally and seek guidance on how to manage the situation effectively. This approach allows the nurse to receive support and potentially gain insights on how to navigate interactions with the manipulative client. Option B is incorrect because avoiding the client may not address the underlying issues causing the reluctance and can impact the quality of care provided. Option C is inappropriate as confronting the client directly about negative behaviors may escalate the situation and harm the therapeutic relationship. Option D is not the immediate action needed in this scenario; it is essential to address the nurse's feelings first before considering behavior modification plans.
5. The caregiver is teaching parents about the diet for a 4-month-old infant with gastroenteritis and mild dehydration. In addition to oral rehydration fluids, the diet should include
- A. Formula or breast milk
- B. Broth and tea
- C. Rice cereal and apple juice
- D. Gelatin and ginger ale
Correct answer: A
Rationale: The correct answer is A: Formula or breast milk. In infants with gastroenteritis and mild dehydration, it is essential to continue feeding them with formula or breast milk along with oral rehydration fluids to provide adequate nutrition and maintain hydration. Option B, broth and tea, may not provide the necessary nutrients and electrolytes needed for the infant's recovery. Option C, rice cereal and apple juice, can be harsh on the digestive system and may exacerbate diarrhea. Option D, gelatin and ginger ale, do not provide the necessary nutrients and can worsen the condition due to the high sugar content in ginger ale.
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