a 16 year old enters the emergency department the triage nurse identifies that this teenager is legally married and signs the consent form for treatme a 16 year old enters the emergency department the triage nurse identifies that this teenager is legally married and signs the consent form for treatme
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Nursing Elites

HESI LPN

HESI Fundamental Practice Exam

1. A 16-year-old enters the emergency department. The triage nurse identifies that this teenager is legally married and signs the consent form for treatment. What would be the appropriate action by the nurse?

Correct answer: D

Rationale: The correct answer is to proceed with the triage process in the same manner as any adult client. In this scenario, since the teenager is legally married, they have the legal authority to consent to their own treatment. Choice A is incorrect because the teenager, being legally married, can provide their own consent. Choice B is incorrect as it unnecessarily delays treatment by waiting for telephone consent from the partner, which is not required in this case. Choice C is incorrect as the teenager can receive appropriate care in the current emergency department setting without the need for referral.

2. As a supervisor, you plan to conduct a seminar in response to the midwife's training need for skills in community diagnosis. Which is an appropriate method to use to enable midwives to apply the knowledge they will gain in actual practice?

Correct answer: B

Rationale: Problem-solving is an effective method to enable midwives to apply the knowledge gained in actual practice. By engaging in problem-solving activities during the seminar, midwives can enhance their critical thinking skills and directly apply the information to real-life scenarios they may encounter in community diagnosis. Choice A (lecture) is less effective as it primarily involves passive listening and may not provide the hands-on experience needed for practical application. Choice C (group discussion) can be helpful for sharing perspectives but may not directly translate to practical application as problem-solving would. Choice D (nominal group technique) focuses more on generating ideas and reaching consensus rather than hands-on application of knowledge.

3. A nurse is caring for a client with major depressive disorder who is withdrawn and refuses to participate in group activities. What is the best nursing intervention?

Correct answer: A

Rationale: Encouraging the client to attend at least one group session is the best nursing intervention in this scenario. By gently encouraging participation, the nurse can help the client start to engage with others, which may gradually improve their mood and social interaction. Choice B, respecting the client's wish to remain isolated, may further exacerbate the client's withdrawal and depression by reinforcing avoidance behavior. Choice C, arranging for individual therapy sessions, can be beneficial but may not address the specific need for social interaction. Choice D, offering a list of activities to choose from, does not directly address the client's difficulty in participating in group activities and may not provide the necessary support in overcoming social withdrawal.

4. A 40-year-old male client diagnosed with schizophrenia and alcohol dependence has not had any visitors or phone calls since admission. He reports he has no family that cares about him and was living on the streets prior to this admission. According to Erikson's theory of psychosocial development, which stage is the client in at this time?

Correct answer: B

Rationale: The client is in Erikson's 'Generativity vs. Stagnation' stage (age 24 to 45). This stage involves maintaining intimate relationships and moving toward developing a family, which the client seems to be struggling with due to lack of visitors and family support. Choices (A), (C), and (D) are incorrect. Isolation typically occurs in young adulthood (age 18 to 25), Despair in maturity (age 45 to death), and Role confusion in adolescence (age 12 to 20). These stages reflect challenges individuals face if they do not successfully navigate their psychosocial developmental tasks.

5. Why should the nurse closely monitor the IV flow rate for a 5-month-old infant with severe diarrhea receiving IV fluids?

Correct answer: D

Rationale: The correct answer is D: Preventing cardiac overload. Infants are highly vulnerable to fluid overload, making it essential to carefully monitor IV flow rates to prevent complications such as cardiac overload. Rapid administration of IV fluids can lead to an excessive increase in circulating volume, potentially causing cardiac strain or heart failure in infants. Choices A, B, and C are incorrect. Monitoring the IV flow rate is not primarily aimed at limiting output, replacing lost fluids, or avoiding IV infiltration in this scenario. The key concern is to prevent the risk of cardiac overload due to the infant's susceptibility to fluid imbalances.

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