HESI LPN
Community Health HESI Exam
1. A male client is brought to the emergency department as the result of a motorcycle accident. He was not wearing a helmet at the time of the accident and states that he has no intention of ever wearing one. Within the framework of the Transtheoretical Model (TTM), which response should the nurse provide?
- A. Wearing a helmet or not is certainly an individual decision.
- B. You should seriously consider wearing a helmet.
- C. Riding a motorcycle with a helmet increases your safety.
- D. I really think you don't have the facts about helmet use.
Correct answer: C
Rationale: Providing information on safety aligns with the TTM framework.
2. Which action should the school nurse take first when conducting a screening for scoliosis?
- A. Compare dorsal trunk measurements
- B. Have the individual extend arms over the head for visualization
- C. Inspect for symmetrical shoulder height
- D. Observe weight-bearing on each leg
Correct answer: C
Rationale: Inspecting for symmetrical shoulder height is a crucial initial step in screening for scoliosis. Asymmetry in shoulder height can indicate the presence of spinal curvature, which is a key indicator of scoliosis. This assessment is prioritized as it provides a visual clue to potential spinal abnormalities. Choices A, B, and D are not the first steps in scoliosis screening. Choice A involves a more detailed measurement that is not the primary visual indicator for scoliosis; choice B is not a primary indicator of scoliosis but can be used for further examination, and choice D is not directly related to identifying spinal curvature.
3. A nurse discovers a small paper fire in a trash can in a client’s bathroom. The client has been taken to safety and the alarm has been activated. Which of the following actions should the nurse take?
- A. Open the windows in the client’s room to allow smoke to escape.
- B. Obtain a class C fire extinguisher to extinguish the fire.
- C. Remove all electrical equipment from the client’s room.
- D. Place wet towels along the base of the door to the client’s room.
Correct answer: B
Rationale: The correct answer is B: Obtain a class C fire extinguisher to extinguish the fire. Using a class C fire extinguisher is appropriate for electrical fires, which can include fires involving electrical equipment or appliances. In this scenario, a paper fire in a trash can in the client's bathroom could potentially involve electrical components, making a class C fire extinguisher the most suitable choice. Option A, opening the windows, may help with ventilation but does not address the fire directly. Option C, removing electrical equipment, is a precautionary measure but does not address the immediate fire hazard. Option D, placing wet towels along the base of the door, is a strategy to prevent smoke from entering the room but does not extinguish the fire.
4. A child is being assessed for suspected appendicitis. What clinical manifestation is the healthcare professional likely to observe?
- A. Right lower quadrant pain
- B. Left lower quadrant pain
- C. Rebound tenderness
- D. Epigastric pain
Correct answer: A
Rationale: Right lower quadrant pain is a classic symptom of appendicitis. The appendix is typically located in the right lower quadrant of the abdomen, so pain in this area is commonly associated with appendicitis. Choices B, C, and D are incorrect because left lower quadrant pain, rebound tenderness, and epigastric pain are not typical manifestations of appendicitis. Left lower quadrant pain is not associated with appendicitis since the appendix is situated in the right lower quadrant. Rebound tenderness is more commonly linked with peritonitis rather than appendicitis. Epigastric pain is not a typical presentation of appendicitis as the pain is usually localized to the right lower quadrant.
5. The nurse is caring for a 15-year-old boy who has sustained burn injuries. The nurse observes the burn developing a purplish color with discharge and a foul odor. The nurse suspects which infection?
- A. Burn wound cellulitis.
- B. Invasive burn cellulitis.
- C. Burn impetigo.
- D. Staphylococcal scalded skin syndrome.
Correct answer: B
Rationale: The correct answer is B: Invasive burn cellulitis. Invasive burn cellulitis presents with the burn developing a dark brown, black, or purplish color with discharge and a foul odor. Burn wound cellulitis (choice A) typically involves redness, warmth, and swelling around the burn site. Burn impetigo (choice C) is a superficial infection characterized by honey-colored crusting. Staphylococcal scalded skin syndrome (choice D) is a condition caused by exotoxins from Staphylococcus aureus, leading to widespread skin peeling.