HESI LPN
Adult Health 1 Final Exam
1. A 4-year-old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy protocol that includes methotrexate, an antimetabolite. Which information should the nurse provide the parents about caring for their child?
- A. Use sunblock or protective clothing when outdoors.
- B. Include the child in regular outings with the family.
- C. Obtain any childhood vaccinations that are not up-to-date.
- D. Use diluted commercial mouthwash for mouth care.
Correct answer: A
Rationale: The correct answer is to use sunblock or protective clothing when outdoors. Methotrexate can cause photosensitivity, making the child more prone to sunburns and skin damage. Therefore, advising the parents to protect their child's skin from direct sunlight exposure is crucial. Choice B is incorrect because exposing the child to direct sunlight without protection can worsen the photosensitivity caused by methotrexate. Choice C is incorrect as obtaining vaccinations is generally avoided during chemotherapy due to the child's compromised immune system. Choice D is incorrect as commercial mouthwash may contain alcohol, which can be irritating to the child's oral mucosa, especially during chemotherapy.
2. A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. What action should the nurse implement?
- A. Attempt to ask the client simple questions.
- B. Postpone the client interview until the next day.
- C. Ask another nurse to talk with the client.
- D. Document the client's paranoid behavior.
Correct answer: A
Rationale: When a client is guarded, suspicious, and resistant to talking, it is important for the nurse to attempt to ask the client simple questions. Simple questions can help build rapport, establish trust, and create a non-threatening environment. This approach may ease the client into more detailed discussions while reducing feelings of suspicion. Postponing the interview may increase the client's anxiety and distrust, while asking another nurse to talk with the client may disrupt continuity of care and the establishment of a therapeutic relationship. Documenting the client's behavior is important for the client's medical record, but it should not be the first action taken in this situation.
3. A family has decided to withhold “extraordinary care” for a newborn with severe abnormalities. How should the nurse interpret this decision?
- A. The newborn has no rights.
- B. It is the same as euthanasia.
- C. It is illegal professional practice.
- D. The newborn is being allowed to die.
Correct answer: D
Rationale: Withholding extraordinary care in cases of severe abnormalities is a legal and ethical decision. It allows the newborn to die naturally without aggressive interventions. Choice A is incorrect because all individuals, including newborns, have rights. Choice B is incorrect because withholding extraordinary care is not equivalent to euthanasia, which involves actively ending a life. Choice C is incorrect because such decisions are legally and ethically permissible when made in consideration of the best interests of the newborn.
4. While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?
- A. The client's comfort level is increased when the nurse maintains eye contact while typing notes into the record
- B. The interview process is hindered by electronic documentation and may disrupt the flow of conversation
- C. The nurse has limited ability to observe nonverbal communication while entering the assessment electronically
- D. Completing the electronic record during an interview is optional and not a legal obligation of the examining nurse
Correct answer: C
Rationale: The most accurate statement is that the nurse has a limited ability to observe nonverbal communication while entering the assessment electronically. This is because the nurse's focus is on typing or inputting data, which may lead to missing important nonverbal cues from the client. Choices A and B are incorrect as they do not address the limitation of observing nonverbal cues. Choice A is incorrect because breaking eye contact to type notes may hinder the client's comfort level. Choice B is incorrect because it states that electronic documentation enhances the interview process, which may not always be the case. Choice D is incorrect as completing the electronic record during an interview is typically a standard practice but not a legal obligation.
5. A nurse is caring for an infant with phenylketonuria (PKU). What diet should the nurse anticipate will be ordered by the health care provider?
- A. Fat-free
- B. Protein-enriched
- C. Phenylalanine-free
- D. Low-phenylalanine
Correct answer: D
Rationale: A low-phenylalanine diet is required for infants with PKU to prevent the buildup of phenylalanine, which can lead to brain damage.