HESI LPN
Medical Surgical Assignment Exam HESI
1. The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition?
- A. Has everyone at home already had varicella?
- B. Have the antifungal creams been effective?
- C. Do your family members share combs and brushes?
- D. Do you have any dry patches on your feet and hands?
Correct answer: A
Rationale: The correct answer is A: 'Has everyone at home already had varicella?' Herpes zoster (shingles) is caused by the reactivation of the varicella-zoster virus, the same virus that causes chickenpox. By knowing if others at home had varicella (chickenpox), the nurse can assess the risk of transmission and provide appropriate guidance. Choice B is incorrect because antifungal creams are not effective for herpes zoster, which is a viral infection. Choice C is irrelevant to herpes zoster as it pertains to sharing personal items that may transmit head lice or certain skin infections. Choice D is also unrelated as it focuses on dry patches, not typical manifestations of herpes zoster which presents as a painful rash.
2. A client with deep vein thrombosis (DVT) is being treated with warfarin. Which dietary instruction should the nurse provide?
- A. Avoid foods high in vitamin C
- B. Increase intake of green leafy vegetables
- C. Limit intake of foods high in vitamin K
- D. Avoid dairy products
Correct answer: C
Rationale: The correct answer is C: 'Limit intake of foods high in vitamin K'. Vitamin K can interfere with the effectiveness of warfarin, an anticoagulant medication commonly used to treat conditions like deep vein thrombosis (DVT). Patients on warfarin should maintain a consistent intake of vitamin K-rich foods and be monitored closely. Choices A, B, and D are incorrect because avoiding foods high in vitamin C, increasing intake of green leafy vegetables, and avoiding dairy products are not essential dietary instructions for a client on warfarin therapy for DVT.
3. A teenage girl has been placed in a brace for the treatment of scoliosis, the most common skeletal deformity of adolescence. The family asks what they can do to be more supportive. What suggestion from the nurse is the most appropriate?
- A. Enrolling her in a health club
- B. Taking her to the mall in a wheelchair
- C. Purchasing clothes to disguise the brace
- D. Spending a majority of their time with her
Correct answer: C
Rationale: The most appropriate suggestion from the nurse is to recommend purchasing clothes to disguise the brace. Adolescents with scoliosis often have body image concerns and wish to fit in with their peers. By providing clothes that help conceal the brace, the family can support the teenage girl's emotional well-being. Choices A, B, and D do not directly address the adolescent's concerns about body image and fitting in, making them less appropriate in this situation.
4. The nurse caring for a hospitalized older client with a left hip fracture as a result of a fall at home notices different assessment findings. Which assessment finding warrants immediate intervention by the nurse?
- A. Pain rated 7/10 on the pain scale.
- B. Mild swelling at the fracture site.
- C. Small amount of bleeding from the surgical site.
- D. Left extremity capillary refill greater than 5 seconds.
Correct answer: D
Rationale: The correct answer is D. A left extremity capillary refill greater than 5 seconds indicates poor blood flow to the extremity, which is a sign of compromised circulation. This finding requires immediate intervention by the nurse to prevent complications such as tissue damage or necrosis. Choices A, B, and C are important assessments but do not indicate an immediate need for intervention like the delayed capillary refill in choice D.
5. A client with Parkinson's disease is experiencing difficulty swallowing. Which intervention should the nurse implement to prevent aspiration?
- A. Encourage the client to eat quickly.
- B. Provide a straw for liquids.
- C. Place the client in an upright position during meals.
- D. Offer thin liquids.
Correct answer: C
Rationale: Placing the client in an upright position during meals is the correct intervention to prevent aspiration in a client with Parkinson's disease. This position helps facilitate swallowing and reduces the risk of aspiration. Choice A is incorrect because encouraging the client to eat quickly can increase the risk of choking and aspiration. Choice B is not the best option as straws may not prevent aspiration effectively. Choice D is incorrect as thin liquids can actually increase the risk of aspiration in individuals with swallowing difficulties.
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