HESI LPN
Fundamentals of Nursing HESI
1. A client with a history of alcoholism is admitted with confusion and ataxia. The LPN/LVN recognizes that these symptoms may be related to a deficiency in which vitamin?
- A. Vitamin A
- B. Vitamin C
- C. Vitamin D
- D. Vitamin B1 (Thiamine)
Correct answer: D
Rationale: The correct answer is Vitamin B1 (Thiamine). Vitamin B1 deficiency, also known as Thiamine deficiency, is common in clients with a history of alcoholism. Thiamine is essential for proper brain function, and its deficiency can lead to neurological symptoms such as confusion and ataxia. Vitamin A, C, and D deficiencies do not typically present with confusion and ataxia in the context of alcoholism. Vitamin A deficiency mainly affects vision, Vitamin C deficiency leads to scurvy with symptoms like bleeding gums, and Vitamin D deficiency is associated with bone disorders. Therefore, they are not the correct choices in this scenario.
2. A female client makes routine visits to a neighborhood community health center. The nurse notes that this client often presents with facial bruising, particularly around the eyes. The nurse discusses prevention of domestic violence with the client even though the client does not admit to being battered. What level of prevention has the nurse applied in this situation?
- A. primary prevention
- B. secondary prevention
- C. tertiary prevention
- D. health promotion
Correct answer: B
Rationale: The correct answer is B: secondary prevention. Secondary prevention involves identifying and addressing issues early to prevent further harm. In this scenario, the nurse is intervening by discussing domestic violence prevention with the client who is showing signs of facial bruising, aiming to prevent further harm even though the client has not disclosed being battered. Choice A (primary prevention) focuses on preventing the onset of a problem before it occurs, like educating about healthy relationships before violence happens. Choice C (tertiary prevention) involves managing and treating the effects of a problem that has already occurred, such as providing counseling to a domestic violence survivor. Choice D (health promotion) aims to enhance well-being and prevent health problems through educational and environmental interventions, which may include aspects of preventing domestic violence, but in this case, the nurse's direct intervention is more about early identification and prevention of harm, aligning it with secondary prevention.
3. How should the RN respond to the mother?
- A. Ask the mother if she has ever thought about harming herself or her child.
- B. Reassure the mother that her child will achieve some growth and development milestones.
- C. Determine if the mother has other children who do not have developmental disabilities.
- D. Encourage the mother to write her thoughts and feelings in a journal.
Correct answer: A
Rationale: The correct response is to ask the mother if she has ever thought about harming herself or her child. This is crucial to assess for suicidal or homicidal thoughts, ensuring the safety of both the mother and the child. Reassuring the mother about achieving some milestones may not address her immediate emotional distress. Inquiring about other children's developmental status is not the priority when safety concerns are present. While journaling can be therapeutic, in this situation, addressing safety takes precedence.
4. While caring for a client receiving parenteral fluid therapy via a peripheral IV catheter, after which of the following observations should the nurse remove the IV catheter?
- A. Swelling and coolness are observed at the IV site.
- B. The client reports mild discomfort at the insertion site.
- C. The infusion rate is slower than expected.
- D. The IV catheter is no longer needed for treatment.
Correct answer: A
Rationale: Swelling and coolness at the IV site can indicate complications such as infiltration, which can lead to tissue damage or fluid leakage into the surrounding tissues. Prompt removal of the IV catheter is essential to prevent further complications. The client reporting mild discomfort at the insertion site is common during IV therapy and does not necessarily warrant catheter removal unless there are signs of infiltration. A slower than expected infusion rate may not always necessitate IV catheter removal; the nurse should troubleshoot potential causes such as kinks in the tubing or pump malfunctions first. Just because the IV catheter is no longer needed for treatment does not automatically mean it should be removed; proper assessment and monitoring for complications are still essential.
5. A nurse in the emergency department is preparing to care for a client who arrived via ambulance. The client is disoriented and has a cardiac arrhythmia. Which of the following actions should the nurse take?
- A. Proceed with treatment without obtaining written consent
- B. Contact the client's next of kin to obtain consent for treatment
- C. Have the client sign a consent for treatment
- D. Notify risk management before initiating treatment
Correct answer: A
Rationale: In emergency situations where a client is disoriented and has a cardiac arrhythmia, obtaining written consent may not be possible due to the urgency of the situation. The priority is to provide immediate treatment to ensure patient safety. Contacting the next of kin or having the client sign a consent form would cause unnecessary delays in providing critical care. Notifying risk management before initiating treatment is not the most appropriate action when dealing with a time-sensitive situation like a cardiac arrhythmia.