HESI LPN
Fundamentals HESI
1. In a client with liver cirrhosis, which symptom would be most concerning during assessment?
- A. Jaundice
- B. Ascites
- C. Hepatomegaly
- D. Altered mental status
Correct answer: D
Rationale: Altered mental status would be the most concerning symptom in a client with liver cirrhosis. It may indicate hepatic encephalopathy, a serious complication requiring immediate intervention. While jaundice, ascites, and hepatomegaly are common in liver cirrhosis, they do not directly correlate with the urgency and severity of hepatic encephalopathy as altered mental status does. Therefore, altered mental status takes priority for immediate attention and intervention.
2. Before administering an antibiotic that can cause nephrotoxicity, which lab value is most important for the nurse to review?
- A. Hemoglobin and Hematocrit
- B. Serum Calcium
- C. Serum Creatinine
- D. WBC
Correct answer: C
Rationale: The correct answer is C: Serum Creatinine. Serum creatinine is a key indicator of kidney function. Reviewing this value is crucial as it helps assess the client's risk for nephrotoxicity before administering the antibiotic. Elevated serum creatinine levels can indicate impaired kidney function, which would increase the risk of nephrotoxicity. Choices A, B, and D are not as directly related to kidney function and nephrotoxicity. Hemoglobin and hematocrit levels assess for anemia, serum calcium levels monitor calcium balance, and WBC count evaluates for infections. While these values are important for overall patient assessment, they are not as specific to assessing nephrotoxicity risk as serum creatinine.
3. A client with a history of seizures is prescribed valproic acid. The nurse should monitor for which potential adverse effect?
- A. Liver toxicity
- B. Kidney stones
- C. Weight gain
- D. Pancreatitis
Correct answer: A
Rationale: Corrected Valproic acid is known to cause liver toxicity as a potential adverse effect. Regular monitoring of liver function tests is crucial to detect any signs of liver damage early on and prevent serious complications. Kidney stones, weight gain, and pancreatitis are not typically associated with valproic acid use, making them incorrect choices in this scenario.
4. A 25-year-old female client has been particularly restless, and the nurse finds her trying to leave the psychiatric unit. She tells the nurse, 'Please let me go! I must leave because the secret police are after me.' Which response is best for the nurse to make?
- A. No one is after you; you're safe here.
- B. You'll feel better after you have rested.
- C. I know you must feel lonely and frightened.
- D. Come with me to your room, and I will sit with you.
Correct answer: D
Rationale: In this scenario, the best response for the nurse is to offer presence and a safe environment without validating the delusion or arguing with the client. By inviting the client to the room and offering to sit with her, the nurse is providing support and reassurance. Choice A is incorrect because directly denying the client's belief may escalate the situation. Choice B is inappropriate as it dismisses the client's concerns without addressing the underlying issue. Choice C acknowledges the client's feelings but does not provide immediate support or safety, unlike Choice D which offers both.
5. Seizures in children most often result from
- A. an abrupt rise in body temperature
- B. an inflammatory process in the brain
- C. a temperature greater than 102°F
- D. a life-threatening infection
Correct answer: A
Rationale: Seizures in children most often result from an abrupt rise in body temperature, leading to febrile seizures. Febrile seizures are common in young children and are typically triggered by a rapid increase in body temperature, often due to infections or other causes. An inflammatory process in the brain (Choice B) is less common as a cause of seizures in children and is usually associated with specific conditions like encephalitis or meningitis. While a temperature greater than 102°F (Choice C) may trigger a febrile seizure, it is the abrupt rise in temperature that is the primary cause. Choice D, a life-threatening infection, is a broad and less specific cause compared to the direct trigger of an abrupt rise in body temperature.