HESI LPN
Adult Health 2 Final Exam
1. During a manic episode, what is the most appropriate intervention to implement first for a client with bipolar disorder?
- A. Engage the client in a quiet activity
- B. Provide a structured environment with minimal stimulation
- C. Monitor the client continuously
- D. Adjust the lighting and noise levels
Correct answer: B
Rationale: During a manic episode, individuals with bipolar disorder may experience sensory overload and agitation. Providing a structured environment with minimal stimulation is the most appropriate initial intervention as it can help reduce overwhelming sensory input and promote a sense of calm. Engaging the client in a quiet activity (Choice A) may not be effective if the environment is still overstimulating. Continuous monitoring (Choice C) is important but may not be the first intervention needed. Adjusting lighting and noise levels (Choice D) can be helpful but may not address the core issue of sensory overload and agitation during a manic episode.
2. The nurse is providing discharge instructions to a client with a diagnosis of peptic ulcer disease (PUD). Which dietary recommendation is most appropriate?
- A. Increase fiber intake.
- B. Avoid spicy foods.
- C. Avoid dairy products.
- D. Consume a high-fat diet.
Correct answer: B
Rationale: The most appropriate dietary recommendation for a client with peptic ulcer disease (PUD) is to avoid spicy foods. Spicy foods can irritate the stomach lining and exacerbate symptoms of PUD. Increasing fiber intake may be beneficial for other gastrointestinal conditions but is not the primary concern for PUD. Avoiding dairy products is not a general recommendation for PUD unless the individual has a specific intolerance. Consuming a high-fat diet can increase the risk of exacerbating PUD symptoms due to the delayed gastric emptying associated with high-fat meals.
3. The nurse is in charge of a Nursing unit in a long-term care facility. Which task is best for the nurse to assign to an unlicensed assistive personnel (UAP) who is helping with the care of several clients?
- A. Measure the amount of a client's residual urine after voiding
- B. Cleanse the perineal area of a client with urinary incontinence
- C. Insert a straight catheter to obtain a urine specimen for culture
- D. Provide catheter care for a client with a suprapubic catheter
Correct answer: B
Rationale: The correct answer is B because cleaning the perineal area is a task within the scope of practice for unlicensed assistive personnel (UAPs) and is crucial for preventing infections. Choice A involves a more complex task that requires a healthcare provider's assessment. Choice C involves a sterile procedure that should be performed by licensed staff. Choice D involves specific care for a client with a catheter that exceeds the UAP's scope of practice.
4. Which of the following are key parameters that produce blood pressure? (Select ONE that does not apply)
- A. Heart rate
- B. Stroke volume
- C. Peripheral resistance
- D. Neuroendocrine hormones
Correct answer: D
Rationale: Heart rate, stroke volume, and peripheral resistance are indeed key parameters that directly influence blood pressure. Heart rate refers to the number of times the heart beats per minute, affecting how much blood is pumped. Stroke volume is the amount of blood pumped by the heart in one contraction. Peripheral resistance is the resistance of the arteries to blood flow, impacting the pressure needed to push blood through. Neuroendocrine hormones, while they can indirectly influence blood pressure regulation by affecting factors like blood volume and vascular tone, are not direct final parameters that produce blood pressure.
5. The nurse is caring for a client with chronic liver disease. Which lab value is most concerning?
- A. Elevated AST and ALT
- B. Decreased albumin level
- C. Elevated bilirubin level
- D. Prolonged PT/INR
Correct answer: D
Rationale: The correct answer is D, prolonged PT/INR. In a client with chronic liver disease, a prolonged PT/INR is the most concerning lab value. This indicates impaired liver function, leading to a higher risk of bleeding. Elevated AST and ALT (choice A) are indicators of liver damage but do not directly assess the risk of bleeding. Decreased albumin level (choice B) reflects impaired liver function but is not as directly related to bleeding risk as a prolonged PT/INR. Elevated bilirubin level (choice C) is a sign of liver dysfunction, specifically related to bile metabolism, and while important, it is not as directly associated with bleeding risk as a prolonged PT/INR in the context of chronic liver disease.
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