HESI LPN
HESI PN Exit Exam
1. A Native American client is admitted with a diagnosis of psychosis not otherwise specified. The client's family seems to regard the client's hallucinations as normal. What assessment can be made?
- A. The client's family regards the hallucinations from a cultural context
- B. The client will benefit from a talking circle
- C. The client will need a medicine man
- D. The client will need a single room
Correct answer: A
Rationale: Choice A is correct because the family may interpret the client's hallucinations through their cultural lens, potentially viewing them as normal or spiritually significant. Understanding and acknowledging the cultural context is essential for providing culturally sensitive care. Choices B, C, and D are incorrect because while talking circles and seeking guidance from a medicine man may be culturally relevant interventions in some contexts, the priority in this situation is to recognize and respect the family's perspective on the client's hallucinations.
2. Which condition is characterized by a progressive loss of muscle strength due to an autoimmune attack on acetylcholine receptors?
- A. Myasthenia gravis
- B. Multiple sclerosis
- C. Amyotrophic lateral sclerosis
- D. Guillain-Barré syndrome
Correct answer: A
Rationale: The correct answer is A: Myasthenia gravis. Myasthenia gravis is characterized by muscle weakness caused by autoimmune attack on acetylcholine receptors at the neuromuscular junction. This results in impaired communication between nerves and muscles. Choice B, Multiple sclerosis, is a condition where the immune system attacks the protective myelin sheath covering the nerves in the central nervous system, leading to communication issues between the brain and the rest of the body. Choice C, Amyotrophic lateral sclerosis, is a progressive neurodegenerative disease affecting motor neurons in the brain and spinal cord, not involving acetylcholine receptors. Choice D, Guillain-Barré syndrome, is an acute condition where the immune system attacks the peripheral nerves, causing muscle weakness and paralysis, but it does not target acetylcholine receptors.
3. A client who is post-operative from a spinal fusion surgery reports a sudden onset of severe headache when sitting up. What is the nurse’s priority action?
- A. Administer pain medication.
- B. Lay the client flat and notify the healthcare provider.
- C. Encourage the client to drink more fluids.
- D. Assess the client’s surgical site for drainage.
Correct answer: B
Rationale: In this scenario, the correct action is to lay the client flat and notify the healthcare provider. A severe headache in a post-operative spinal fusion patient can indicate a spinal fluid leak, which is a medical emergency. By laying the client flat, the nurse helps reduce symptoms by decreasing pressure differentials. Administering pain medication without further assessment or intervention is inappropriate before identifying the cause of the headache. Encouraging the client to drink more fluids is not the priority when a serious complication like a spinal fluid leak is suspected. While assessing the surgical site is important, it is not the priority when a potentially life-threatening complication is suspected.
4. The PN is caring for a client with schizophrenia who continues to repeat the last words heard. Which nursing problem should the PN document in the medical record?
- A. Altered thought processes
- B. Impaired social interaction
- C. Risk for self-directed violence
- D. Disturbed thought processes
Correct answer: D
Rationale: The correct answer is D: Disturbed thought processes. Echolalia, the repetition of heard words, is associated with disturbed thought processes, which are commonly seen in schizophrenia. Altered thought processes (Choice A) is a generic term and does not specifically address the behavior of repeating words. Impaired social interaction (Choice B) is not the primary concern when a client repeats the last words heard. Risk for self-directed violence (Choice C) is not directly related to the behavior of repeating words but focuses on the potential harm the client may cause to themselves.
5. Which intervention is most appropriate when caring for a patient experiencing a tonic-clonic seizure?
- A. Restrain the patient to prevent injury
- B. Place a tongue depressor in the patient's mouth
- C. Turn the patient to the side to maintain an open airway
- D. Attempt to stop the seizure by holding the patient’s arms
Correct answer: C
Rationale: During a tonic-clonic seizure, the priority is to ensure patient safety by maintaining an open airway to prevent aspiration. Turning the patient to the side helps achieve this goal by allowing any fluids to drain out of the mouth, reducing the risk of choking or aspiration. Restraint can lead to injury, placing a tongue depressor can cause harm or obstruct the airway further, and attempting to stop the seizure by holding the patient's arms is ineffective and can also result in injury. Therefore, the most appropriate intervention is to turn the patient to the side.
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