Medical Surgical HESI

HESI LPN

1. Which additional congenital malformation is expected in 80% of infants with a myelomeningocele?

A. Cerebral palsy
B. Hydrocephalus
C. Meningitis
D. Neuroblastoma

Correct answer: B

Rationale: Hydrocephalus is the additional congenital malformation expected in 80% of infants with a myelomeningocele. Myelomeningocele is commonly associated with hydrocephalus due to the abnormal accumulation of cerebrospinal fluid in the brain. Cerebral palsy (Choice A) is a motor disorder but not typically associated with myelomeningocele. Meningitis (Choice C) is an infection of the meninges and is not a congenital malformation. Neuroblastoma (Choice D) is a type of cancer that originates in immature nerve cells and is not a typical association with myelomeningocele.

2. Twelve hours following a unilateral total knee replacement, a client reports being unable to sleep because of severe incisional pain. What is the best initial nursing action?

A. Administer a prescribed sedative.
B. Reposition the client for comfort.
C. Apply ice packs to the surgical site.
D. Instruct the client in the use of the prescribed patient-controlled analgesia (PCA) pump.

Correct answer: D

Rationale: Instructing the client in the use of the PCA pump is the best initial nursing action for managing severe incisional pain after knee replacement surgery. The PCA pump allows the client to self-administer pain medication effectively, promoting better pain management. Administering a sedative may mask the pain temporarily but doesn't address the root cause. Repositioning the client for comfort or applying ice packs may provide some relief but doesn't address the need for effective pain control as the PCA pump does.

3. The nurse provides dietary instructions about iron-rich foods to a client with iron deficiency anemia. Which food selection made by the client indicates a need for additional instructions?

A. Liver.
B. Oranges.
C. Leafy green vegetables.
D. Kidney beans.

Correct answer: B

Rationale: The correct answer is B: Oranges. Oranges are not a rich source of iron. Iron-rich foods include liver, leafy green vegetables, and kidney beans. Oranges are a good source of vitamin C but are not high in iron. Therefore, if the client selects oranges as an iron-rich food, it indicates a need for additional instructions on choosing foods high in iron.

4. What are early signs of varicella disease?

A. High fever over 101°F (38.3°C)
B. General malaise
C. Increased appetite
D. Crusty sores

Correct answer: B

Rationale: The correct early sign of varicella disease is general malaise. During the prodromal period, patients may experience low-grade fever, malaise, and anorexia. Increased appetite and crusty sores are not typically early signs of varicella. The appearance of lesions occurs later in the course of the disease.

5. The nurse is caring for a client with a suspected stroke. Which assessment finding is most indicative of a stroke?

A. Chest pain
B. Sudden confusion and difficulty speaking
C. Gradual onset of weakness in the legs
D. Nausea and vomiting

Correct answer: B

Rationale: The correct answer is B: Sudden confusion and difficulty speaking. These are classic signs of a stroke, indicating a neurological deficit that requires urgent medical attention. Choices A, C, and D are less indicative of a stroke. Chest pain is more commonly associated with cardiac issues, gradual onset of weakness in the legs could be related to other conditions like peripheral neuropathy, and nausea/vomiting may suggest gastrointestinal problems rather than a stroke.