HESI LPN
Adult Health 1 Exam 1
1. A client requires application of an eye shield to the right eye. What should the nurse do in order to apply tape to anchor the shield most effectively?
- A. Place tape from the cheek to the forehead
- B. Secure tape from the nose to the ear
- C. Attach tape from the lower eyelid to the upper forehead
- D. Use circular bandaging around the head
Correct answer: C
Rationale: The correct way to apply tape to anchor an eye shield effectively is to attach the tape from the lower eyelid to the upper forehead. This method provides stability for the shield without putting pressure on the eye itself, thus helping to protect the eye. Choices A, B, and D are incorrect because taping from the cheek to the forehead, securing tape from the nose to the ear, or using circular bandaging around the head may not provide the necessary stability and protection required for the eye shield.
2. A client with a diagnosis of major depressive disorder is prescribed fluoxetine (Prozac). What is the most important side effect for the LPN/LVN to monitor?
- A. Weight gain.
- B. Sexual dysfunction.
- C. Nausea.
- D. Constipation.
Correct answer: B
Rationale: The correct answer is B: Sexual dysfunction. When monitoring a client taking fluoxetine (Prozac), the LPN/LVN should prioritize observing for sexual dysfunction. This side effect is crucial to monitor as it can significantly impact the client's quality of life and may affect their adherence to the medication. Weight gain (choice A) is a possible side effect of fluoxetine but is not as critical as sexual dysfunction in terms of monitoring. Nausea (choice C) and constipation (choice D) are common side effects of fluoxetine, but they are generally less concerning compared to the impact of sexual dysfunction on the client's well-being and treatment compliance.
3. A client is admitted with a diagnosis of myocardial infarction (MI). Which intervention is a priority during the acute phase?
- A. Administer morphine for pain relief
- B. Encourage the client to perform isometric exercises
- C. Position the client flat in bed
- D. Restrict fluid intake
Correct answer: A
Rationale: During the acute phase of a myocardial infarction (MI), the priority intervention is to administer morphine for pain relief. Morphine not only alleviates pain but also reduces myocardial oxygen demand, which is crucial in the management of MI. Encouraging the client to perform isometric exercises (choice B) can increase myocardial oxygen demand and should be avoided during the acute phase. Positioning the client flat in bed (choice C) may worsen symptoms by increasing venous return and workload on the heart. Restricting fluid intake (choice D) is not a priority intervention during the acute phase of MI; maintaining adequate hydration is important for organ perfusion.
4. The occurrence of non-communicable diseases (NCDs) is on the rise and is attributed to the changing lifestyle of Filipinos. The major NCDs are cardiovascular diseases (CVDs), cancer, chronic obstructive pulmonary disease (COPD), and diabetes mellitus (DM). The community health nurse can help address these problems. The major risk factors common to the above-mentioned four major NCDs are:
- A. Unhealthy diet, physical inactivity, and smoking
- B. Hypertension, sedentary lifestyle, and poor stress management
- C. Obesity, sedentary lifestyle, and smoking
- D. Unhealthy diet, alcoholism, and sedentary lifestyle
Correct answer: A
Rationale: The correct answer is A: 'Unhealthy diet, physical inactivity, and smoking.' These are major risk factors associated with cardiovascular diseases (CVDs), cancer, chronic obstructive pulmonary disease (COPD), and diabetes mellitus (DM). Unhealthy diet can lead to obesity and other health issues, physical inactivity contributes to various chronic conditions, and smoking is a well-known risk factor for cancer and respiratory diseases. Choice B is incorrect as hypertension is a condition that can result from these risk factors rather than being a risk factor itself. Poor stress management, although important for overall health, is not a major risk factor for the mentioned NCDs. Choice C is incorrect as although obesity is a risk factor, it is not mentioned in the question stem. Choice D is incorrect as alcoholism is not listed among the major NCDs or the common risk factors provided.
5. A client had a mastectomy 6 months ago and expresses a decreased desire for sexual relations, stating “My body is so different now.” Which of the following responses should the nurse make?
- A. “Really, you look just fine to me. There’s no need to feel undesirable.”
- B. “I’m interested in finding out more about how your body feels to you.”
- C. “Consider an afternoon at a spa; a facial will make you feel more attractive.”
- D. “It’s still too soon to expect to feel normal. Give it a little more time.”
Correct answer: B
Rationale: In this situation, the appropriate response is to reflect on the client’s feelings and explore their experience. Choice A may unintentionally dismiss the client's concerns by not addressing their emotional needs. Choice C suggests a spa treatment as a solution without addressing the underlying emotional issues. Choice D implies that the client's feelings will resolve with time, which may not be helpful in addressing the client's current emotional state.