HESI LPN
Medical Surgical HESI 2023
1. A male client tells the nurse that he is experiencing burning on urination, and assessment reveals that he had sexual intercourse four days ago with a woman he casually met. Which action should the nurse implement?
- A. Observe the perineal area for a chancroid-like lesion.
- B. Obtain a specimen of urethral drainage for culture.
- C. Assess for perineal itching, erythema, and excoriation.
- D. Identify all sexual partners in the last four days.
Correct answer: B
Rationale: In this scenario, the most appropriate action for the nurse to take is to obtain a specimen of urethral drainage for culture. This procedure can help diagnose the cause of burning on urination, which could be indicative of a sexually transmitted infection. Option A, observing for a chancroid-like lesion, may not be the most immediate or relevant action in this case. Option C, assessing for perineal itching, erythema, and excoriation, is important but obtaining a culture specimen would provide more specific diagnostic information. Option D, identifying all sexual partners, is relevant for contact tracing but obtaining a culture specimen is the priority to determine the current infection status.
2. You are caring for a neonate who has a cleft palate. You should inform the mother that surgical correction will be done when the infant is:
- A. 8 to 12 months of age.
- B. 20 to 24 months of age.
- C. 16 to 20 months of age.
- D. 12 to 16 months of age.
Correct answer: A
Rationale: The correct answer is A: 8 to 12 months of age. Surgical correction for a cleft palate is typically performed around this age to optimize speech development and prevent feeding difficulties. Options B, C, and D suggest later ages for surgery, which may lead to speech and feeding issues due to the delay in correction.
3. A 46-year-old female client has been on antipsychotic neuroleptic medication for the past three days. She has had a decrease in psychotic behavior and appears to be responding well to the medication. On the fourth day, the client's blood pressure increases, she becomes pale and febrile, and demonstrates muscular rigidity. Which action will the nurse initiate?
- A. Place the client on seizure precautions and monitor closely.
- B. Immediately transfer the client to the ICU.
- C. Report the symptoms to the charge nurse and document in the client's chart.
- D. No action is required at this time as these are known side effects of such medications.
Correct answer: B
Rationale: These symptoms are indicative of neuroleptic malignant syndrome (NMS), which is a severe and life-threatening reaction to neuroleptic drugs. The major symptoms include fever, rigidity, autonomic instability, and encephalopathy. Respiratory failure, cardiovascular collapse, arrhythmias, and/or renal failure can lead to death. This is an emergency situation requiring immediate critical care, thus the correct action is to transfer the client to the ICU (B). Seizure precautions (A) are not relevant in this scenario. Merely describing the symptoms to the charge nurse and documenting them (C) or taking no action assuming these are common side effects (D) fail to address the critical nature of the situation and the urgency of immediate intervention.
4. An assistive personnel says to the nurse, “This client is incontinent of stool three or four times a day. I get angry, and I think that the client is doing it just to get attention. I think we should put adult diapers on her.” Which is the appropriate nursing response?
- A. You should report this to the supervisor
- B. It is very upsetting to see an adult client regress
- C. Diapers are the best solution
- D. The client’s condition is not your concern
Correct answer: B
Rationale: The correct response is 'It is very upsetting to see an adult client regress.' In this situation, the nurse should acknowledge the emotional impact of caregiving on the assistive personnel and address it professionally. Choice A is incorrect because reporting to the supervisor may not directly address the emotional concerns raised. Choice C is incorrect because immediately resorting to diapers without further assessment or intervention is not the most appropriate solution. Choice D is incorrect as the client's well-being and care are a shared responsibility among healthcare team members.
5. Parents of a 5-year-old child diagnosed with cognitive impairment have come to the nurse to discuss different approaches to the ongoing care of their child. The nurse should suggest focusing on what activity?
- A. Acquiring job skills
- B. Making decisions
- C. Performing self-care activities
- D. Reading and doing simple math
Correct answer: C
Rationale: The correct answer is C: Performing self-care activities. For a 5-year-old child diagnosed with cognitive impairment, it is crucial to focus on teaching them basic self-care skills. This includes activities like dressing themselves, feeding, and personal hygiene. These skills are fundamental for their daily living and independence. Choices A, B, and D are not appropriate for a young child with cognitive impairment. Acquiring job skills is not developmentally suitable at this age, making decisions may be challenging due to cognitive limitations, and reading and doing simple math may be too advanced for their current cognitive abilities.