HESI LPN
Fundamentals HESI
1. During assessment, what is a nurse monitoring when assessing body alignment?
- A. The relationship of one body part to another in different positions
- B. The coordination between musculoskeletal and nervous systems
- C. The force opposing movement direction
- D. The ability to move freely
Correct answer: A
Rationale: When a nurse assesses body alignment, they are observing the relationship of one body part to another in various positions. This involves evaluating the positioning of joints, tendons, ligaments, and muscles while a person is standing, sitting, or lying down. Choice B is incorrect because it refers more to the coordination between the musculoskeletal and nervous systems, which is not specifically related to body alignment assessment. Choice C is incorrect as it describes the force opposing movement rather than body alignment. Choice D is incorrect as it defines the ability to move freely, which is not directly related to monitoring body alignment.
2. The healthcare provider is observing the way a patient walks. Which aspect is the healthcare provider assessing?
- A. Activity tolerance
- B. Body alignment
- C. Range of motion
- D. Gait
Correct answer: D
Rationale: When assessing the way a patient walks, the healthcare provider is evaluating the gait, which refers to a particular manner or style of walking. Body alignment pertains to the positioning of body parts in relation to one another, range of motion refers to the extent of movement of a joint, and activity tolerance relates to the ability to endure physical activities. In this scenario, observing the patient's walking pattern specifically focuses on gait assessment.
3. Which behavior indicates the nurse is using a team approach when caring for a patient who is experiencing alterations in mobility?
- A. Delegates assessment of lung sounds to nursing assistive personnel
- B. Becomes solely responsible for modifying activities of daily living
- C. Consults physical therapy for strengthening exercises in the extremities
- D. Involves respiratory therapy for altered breathing from severe anxiety levels
Correct answer: C
Rationale: Consulting physical therapy for strengthening exercises in the extremities demonstrates a team approach in caring for a patient with mobility issues. Involving other healthcare professionals like physical therapists ensures a comprehensive and specialized approach to address the patient's mobility needs. This collaborative approach benefits the patient by providing specialized interventions. Choices A, B, and D do not exemplify a collaborative team approach. Delegating assessment tasks to nursing assistive personnel (Choice A) may not address the mobility issue directly. Becoming solely responsible for modifying activities of daily living (Choice B) limits the scope of interventions. Involving respiratory therapy for anxiety-related breathing issues (Choice D) addresses a different aspect of care and does not directly target mobility concerns.
4. A nurse delegates a position change to a nursing assistive personnel. The nurse instructs the assistive personnel (AP) to place the patient in the lateral position. Which finding by the nurse indicates a correct outcome?
- A. Patient is lying on side.
- B. Patient is lying on back.
- C. Patient is lying semiprone.
- D. Patient is lying on abdomen.
Correct answer: A
Rationale: The correct answer is A: 'Patient is lying on side.' In the side-lying (or lateral) position, the patient rests on the side with the major portion of body weight on the dependent hip and shoulder. Choice B, 'Patient is lying on back,' is incorrect as it describes a supine position. Choice C, 'Patient is lying semiprone,' is incorrect as it refers to a position where the patient is partially lying on the abdomen. Choice D, 'Patient is lying on abdomen,' is incorrect as it describes a prone position where the patient is lying face down.
5. The patient refuses to bathe in the morning, stating a preference for evening baths. What is the best action for the nurse?
- A. Defer the bath until evening and pass on the information to the next shift.
- B. Tell the patient that daily morning baths are part of the 'normal' routine.
- C. Explain the importance of maintaining morning hygiene practices.
- D. Cancel hygiene for the day and attempt again in the morning.
Correct answer: A
Rationale: The best action by the nurse is to respect the patient's preference and autonomy. Defer the bath until evening to allow the patient to follow their usual hygiene routine. Passing on the information to the next shift ensures continuity of care. Choice B is incorrect because it disregards the patient's preference and autonomy. Choice C, while important, does not address the patient's immediate concern. Choice D is incorrect as it does not respect the patient's wishes and may lead to further resistance to bathing.
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